hospital_name,last_updated_on,version,location_name,hospital_address,license_number|FL,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Mount Sinai Medical Center of Florida,    2026-03-13,3.0.0,Miami Beach Main Campus | Hialeah ED | Aventura ED,"4300 Alton Road Miami Beach FL 33140 | 6050 W 20th Ave Hialeah FL 33016 | 2845 NE 199th St, Miami, FL 33180",4066,1912964768 | 1821049172 | 1902857386,TRUE,Gino Santorio,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,modifiers,setting,billing_class,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|min,standard_charge|max,additional_generic_notes,standard_charge|Aetna Health|Aetna|negotiated_dollar,standard_charge|Aetna Health|Aetna|negotiated_percentage,standard_charge|Aetna Health|Aetna|negotiated_algorithm,standard_charge|Aetna Health|Aetna|methodology,median_amount|Aetna Health|Aetna,10th_percentile|Aetna Health|Aetna,90th_percentile|Aetna Health|Aetna,count|Aetna Health|Aetna,additional_payer_notes|Aetna Health|Aetna,standard_charge|Aetna Health|Aetna Better Health|negotiated_dollar,standard_charge|Aetna Health|Aetna Better Health|negotiated_percentage,standard_charge|Aetna Health|Aetna Better Health|negotiated_algorithm,standard_charge|Aetna Health|Aetna Better Health|methodology,median_amount|Aetna Health|Aetna Better Health,10th_percentile|Aetna Health|Aetna Better Health,90th_percentile|Aetna Health|Aetna Better Health,count|Aetna Health|Aetna Better Health,additional_payer_notes|Aetna Health|Aetna Better Health,standard_charge|Aetna International PPO|Aetna International PPO|negotiated_dollar,standard_charge|Aetna International PPO|Aetna International PPO|negotiated_percentage,standard_charge|Aetna International PPO|Aetna International PPO|negotiated_algorithm,standard_charge|Aetna International PPO|Aetna International PPO|methodology,median_amount|Aetna International PPO|Aetna International PPO,10th_percentile|Aetna International PPO|Aetna International PPO,90th_percentile|Aetna International PPO|Aetna International PPO,count|Aetna International PPO|Aetna International PPO,additional_payer_notes|Aetna International PPO|Aetna International PPO,standard_charge|Aetna Health|Aetna Medicare|negotiated_dollar,standard_charge|Aetna Health|Aetna Medicare|negotiated_percentage,standard_charge|Aetna Health|Aetna Medicare|negotiated_algorithm,standard_charge|Aetna Health|Aetna Medicare|methodology,median_amount|Aetna Health|Aetna Medicare,10th_percentile|Aetna Health|Aetna Medicare,90th_percentile|Aetna Health|Aetna Medicare,count|Aetna Health|Aetna Medicare,additional_payer_notes|Aetna Health|Aetna Medicare,standard_charge|Aetna Health|Aetna Workers Comp|negotiated_dollar,standard_charge|Aetna Health|Aetna Workers Comp|negotiated_percentage,standard_charge|Aetna Health|Aetna Workers Comp|negotiated_algorithm,standard_charge|Aetna Health|Aetna Workers Comp|methodology,median_amount|Aetna Health|Aetna Workers Comp,10th_percentile|Aetna Health|Aetna Workers Comp,90th_percentile|Aetna Health|Aetna Workers Comp,count|Aetna Health|Aetna Workers Comp,additional_payer_notes|Aetna Health|Aetna Workers Comp,standard_charge|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp|negotiated_dollar,standard_charge|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp|negotiated_percentage,standard_charge|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp|negotiated_algorithm,standard_charge|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp|methodology,median_amount|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp,10th_percentile|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp,90th_percentile|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp,count|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp,additional_payer_notes|Aetna/Coventry Workers Comp|Aetna/Coventry Workers Comp,standard_charge|Align Senior Care|Align Senior Care|negotiated_dollar,standard_charge|Align Senior Care|Align Senior Care|negotiated_percentage,standard_charge|Align Senior Care|Align Senior Care|negotiated_algorithm,standard_charge|Align Senior Care|Align Senior Care|methodology,median_amount|Align Senior Care|Align Senior Care,10th_percentile|Align Senior Care|Align Senior Care,90th_percentile|Align Senior Care|Align Senior Care,count|Align Senior Care|Align Senior Care,additional_payer_notes|Align Senior Care|Align Senior Care,standard_charge|Ambetter|Ambetter|negotiated_dollar,standard_charge|Ambetter|Ambetter|negotiated_percentage,standard_charge|Ambetter|Ambetter|negotiated_algorithm,standard_charge|Ambetter|Ambetter|methodology,median_amount|Ambetter|Ambetter,10th_percentile|Ambetter|Ambetter,90th_percentile|Ambetter|Ambetter,count|Ambetter|Ambetter,additional_payer_notes|Ambetter|Ambetter,standard_charge|AvMed Broad Network|AvMed Broad Network|negotiated_dollar,standard_charge|AvMed Broad Network|AvMed Broad Network|negotiated_percentage,standard_charge|AvMed Broad Network|AvMed Broad Network|negotiated_algorithm,standard_charge|AvMed Broad Network|AvMed Broad Network|methodology,median_amount|AvMed Broad Network|AvMed Broad Network,10th_percentile|AvMed Broad Network|AvMed Broad Network,90th_percentile|AvMed Broad Network|AvMed Broad Network,count|AvMed Broad Network|AvMed Broad Network,additional_payer_notes|AvMed Broad Network|AvMed Broad Network,standard_charge|AvMed HIX Network|AvMed HIX Network|negotiated_dollar,standard_charge|AvMed HIX Network|AvMed HIX Network|negotiated_percentage,standard_charge|AvMed HIX Network|AvMed HIX Network|negotiated_algorithm,standard_charge|AvMed HIX Network|AvMed HIX Network|methodology,median_amount|AvMed HIX Network|AvMed HIX Network,10th_percentile|AvMed HIX Network|AvMed HIX Network,90th_percentile|AvMed HIX Network|AvMed HIX Network,count|AvMed HIX Network|AvMed HIX Network,additional_payer_notes|AvMed HIX Network|AvMed HIX Network,standard_charge|AvMed Medicare Network|AvMed Medicare Network|negotiated_dollar,standard_charge|AvMed Medicare Network|AvMed Medicare Network|negotiated_percentage,standard_charge|AvMed Medicare Network|AvMed Medicare Network|negotiated_algorithm,standard_charge|AvMed Medicare Network|AvMed Medicare Network|methodology,median_amount|AvMed Medicare Network|AvMed Medicare Network,10th_percentile|AvMed Medicare Network|AvMed Medicare Network,90th_percentile|AvMed Medicare Network|AvMed Medicare Network,count|AvMed Medicare Network|AvMed Medicare Network,additional_payer_notes|AvMed Medicare Network|AvMed Medicare Network,standard_charge|AvMed Select Network|AvMed Select Network|negotiated_dollar,standard_charge|AvMed Select Network|AvMed Select Network|negotiated_percentage,standard_charge|AvMed Select Network|AvMed Select Network|negotiated_algorithm,standard_charge|AvMed Select Network|AvMed Select Network|methodology,median_amount|AvMed Select Network|AvMed Select Network,10th_percentile|AvMed Select Network|AvMed Select Network,90th_percentile|AvMed Select Network|AvMed Select Network,count|AvMed Select Network|AvMed Select Network,additional_payer_notes|AvMed Select Network|AvMed Select Network,standard_charge|Health Options Inc|BCBS Health Options HMO|negotiated_dollar,standard_charge|Health Options Inc|BCBS Health Options HMO|negotiated_percentage,standard_charge|Health Options Inc|BCBS Health Options HMO|negotiated_algorithm,standard_charge|Health Options Inc|BCBS Health Options HMO|methodology,median_amount|Health Options Inc|BCBS Health Options HMO,10th_percentile|Health Options Inc|BCBS Health Options HMO,90th_percentile|Health Options Inc|BCBS Health Options HMO,count|Health Options Inc|BCBS Health Options HMO,additional_payer_notes|Health Options Inc|BCBS Health Options HMO,standard_charge|Health Options Inc|BCBS Health Options Medicare|negotiated_dollar,standard_charge|Health Options Inc|BCBS Health Options Medicare|negotiated_percentage,standard_charge|Health Options Inc|BCBS Health Options Medicare|negotiated_algorithm,standard_charge|Health Options Inc|BCBS Health Options Medicare|methodology,median_amount|Health Options Inc|BCBS Health Options Medicare,10th_percentile|Health Options Inc|BCBS Health Options Medicare,90th_percentile|Health Options Inc|BCBS Health Options Medicare,count|Health Options Inc|BCBS Health Options Medicare,additional_payer_notes|Health Options Inc|BCBS Health Options Medicare,standard_charge|Blue Cross Blue Shield of Florida|BCBS Medicare PPO|negotiated_dollar,standard_charge|Blue Cross Blue Shield of Florida|BCBS Medicare PPO|negotiated_percentage,standard_charge|Blue Cross Blue Shield of Florida|BCBS Medicare PPO|negotiated_algorithm,standard_charge|Blue Cross Blue Shield of Florida|BCBS Medicare PPO|methodology,median_amount|Blue Cross Blue Shield of Florida|BCBS Medicare PPO,10th_percentile|Blue Cross Blue Shield of Florida|BCBS Medicare PPO,90th_percentile|Blue Cross Blue Shield of Florida|BCBS Medicare PPO,count|Blue Cross Blue Shield of Florida|BCBS Medicare PPO,additional_payer_notes|Blue Cross Blue Shield of Florida|BCBS Medicare PPO,standard_charge|Blue Cross Blue Shield of Florida|BCBS Network Blue|negotiated_dollar,standard_charge|Blue Cross Blue Shield of Florida|BCBS Network Blue|negotiated_percentage,standard_charge|Blue Cross Blue Shield of Florida|BCBS Network Blue|negotiated_algorithm,standard_charge|Blue Cross Blue Shield of Florida|BCBS Network Blue|methodology,median_amount|Blue Cross Blue Shield of Florida|BCBS Network Blue,10th_percentile|Blue Cross Blue Shield of Florida|BCBS Network Blue,90th_percentile|Blue Cross Blue Shield of Florida|BCBS Network Blue,count|Blue Cross Blue Shield of Florida|BCBS Network Blue,additional_payer_notes|Blue Cross Blue Shield of Florida|BCBS Network Blue,standard_charge|Blue Cross Blue Shield of Florida|BCBS PPO|negotiated_dollar,standard_charge|Blue Cross Blue Shield of Florida|BCBS PPO|negotiated_percentage,standard_charge|Blue Cross Blue Shield of Florida|BCBS PPO|negotiated_algorithm,standard_charge|Blue Cross Blue Shield of Florida|BCBS PPO|methodology,median_amount|Blue Cross Blue Shield of Florida|BCBS PPO,10th_percentile|Blue Cross Blue Shield of Florida|BCBS PPO,90th_percentile|Blue Cross Blue Shield of Florida|BCBS PPO,count|Blue Cross Blue Shield of Florida|BCBS PPO,additional_payer_notes|Blue Cross Blue Shield of Florida|BCBS PPO,standard_charge|Blue Cross Blue Shield of Florida|BCBS Rehab PPO|negotiated_dollar,standard_charge|Blue Cross Blue Shield of Florida|BCBS Rehab PPO|negotiated_percentage,standard_charge|Blue Cross Blue Shield of Florida|BCBS Rehab PPO|negotiated_algorithm,standard_charge|Blue Cross Blue Shield of Florida|BCBS Rehab PPO|methodology,median_amount|Blue Cross Blue Shield of Florida|BCBS Rehab PPO,10th_percentile|Blue Cross Blue Shield of Florida|BCBS Rehab PPO,90th_percentile|Blue Cross Blue Shield of Florida|BCBS Rehab PPO,count|Blue Cross Blue Shield of Florida|BCBS Rehab PPO,additional_payer_notes|Blue Cross Blue Shield of Florida|BCBS Rehab PPO,standard_charge|Blue Cross Blue Shield of Florida|BCBS Traditional|negotiated_dollar,standard_charge|Blue Cross Blue Shield of Florida|BCBS Traditional|negotiated_percentage,standard_charge|Blue Cross Blue Shield of Florida|BCBS Traditional|negotiated_algorithm,standard_charge|Blue Cross Blue Shield of Florida|BCBS Traditional|methodology,median_amount|Blue Cross Blue Shield of Florida|BCBS Traditional,10th_percentile|Blue Cross Blue Shield of Florida|BCBS Traditional,90th_percentile|Blue Cross Blue Shield of Florida|BCBS Traditional,count|Blue Cross Blue Shield of Florida|BCBS Traditional,additional_payer_notes|Blue Cross Blue Shield of Florida|BCBS Traditional,standard_charge|Blue Cross Blue Shield of Florida|BCBS Workers Compensation|negotiated_dollar,standard_charge|Blue Cross Blue Shield of Florida|BCBS Workers Compensation|negotiated_percentage,standard_charge|Blue Cross Blue Shield of Florida|BCBS Workers Compensation|negotiated_algorithm,standard_charge|Blue Cross Blue Shield of Florida|BCBS Workers Compensation|methodology,median_amount|Blue Cross Blue Shield of Florida|BCBS Workers Compensation,10th_percentile|Blue Cross Blue Shield of Florida|BCBS Workers Compensation,90th_percentile|Blue Cross Blue Shield of Florida|BCBS Workers Compensation,count|Blue Cross Blue Shield of Florida|BCBS Workers Compensation,additional_payer_notes|Blue Cross Blue Shield of Florida|BCBS Workers Compensation,standard_charge|Beech Street|Beech Street|negotiated_dollar,standard_charge|Beech Street|Beech Street|negotiated_percentage,standard_charge|Beech Street|Beech Street|negotiated_algorithm,standard_charge|Beech Street|Beech Street|methodology,median_amount|Beech Street|Beech Street,10th_percentile|Beech Street|Beech Street,90th_percentile|Beech Street|Beech Street,count|Beech Street|Beech Street,additional_payer_notes|Beech Street|Beech Street,standard_charge|Behavioral Services Network|Behavioral Services Network|negotiated_dollar,standard_charge|Behavioral Services Network|Behavioral Services Network|negotiated_percentage,standard_charge|Behavioral Services Network|Behavioral Services Network|negotiated_algorithm,standard_charge|Behavioral Services Network|Behavioral Services Network|methodology,median_amount|Behavioral Services Network|Behavioral Services Network,10th_percentile|Behavioral Services Network|Behavioral Services Network,90th_percentile|Behavioral Services Network|Behavioral Services Network,count|Behavioral Services Network|Behavioral Services Network,additional_payer_notes|Behavioral Services Network|Behavioral Services Network,standard_charge|Bright Health|Bright Health|negotiated_dollar,standard_charge|Bright Health|Bright Health|negotiated_percentage,standard_charge|Bright Health|Bright Health|negotiated_algorithm,standard_charge|Bright Health|Bright Health|methodology,median_amount|Bright Health|Bright Health,10th_percentile|Bright Health|Bright Health,90th_percentile|Bright Health|Bright Health,count|Bright Health|Bright Health,additional_payer_notes|Bright Health|Bright Health,standard_charge|Bright Health Medicare|Bright Health Medicare|negotiated_dollar,standard_charge|Bright Health Medicare|Bright Health Medicare|negotiated_percentage,standard_charge|Bright Health Medicare|Bright Health Medicare|negotiated_algorithm,standard_charge|Bright Health Medicare|Bright Health Medicare|methodology,median_amount|Bright Health Medicare|Bright Health Medicare,10th_percentile|Bright Health Medicare|Bright Health Medicare,90th_percentile|Bright Health Medicare|Bright Health Medicare,count|Bright Health Medicare|Bright Health Medicare,additional_payer_notes|Bright Health Medicare|Bright Health Medicare,standard_charge|Care Management Network|Care Management Network|negotiated_dollar,standard_charge|Care Management Network|Care Management Network|negotiated_percentage,standard_charge|Care Management Network|Care Management Network|negotiated_algorithm,standard_charge|Care Management Network|Care Management Network|methodology,median_amount|Care Management Network|Care Management Network,10th_percentile|Care Management Network|Care Management Network,90th_percentile|Care Management Network|Care Management Network,count|Care Management Network|Care Management Network,additional_payer_notes|Care Management Network|Care Management Network,standard_charge|CarePlus|CarePlus|negotiated_dollar,standard_charge|CarePlus|CarePlus|negotiated_percentage,standard_charge|CarePlus|CarePlus|negotiated_algorithm,standard_charge|CarePlus|CarePlus|methodology,median_amount|CarePlus|CarePlus,10th_percentile|CarePlus|CarePlus,90th_percentile|CarePlus|CarePlus,count|CarePlus|CarePlus,additional_payer_notes|CarePlus|CarePlus,standard_charge|Careworks Workers Comp|Careworks Workers Comp|negotiated_dollar,standard_charge|Careworks Workers Comp|Careworks Workers Comp|negotiated_percentage,standard_charge|Careworks Workers Comp|Careworks Workers Comp|negotiated_algorithm,standard_charge|Careworks Workers Comp|Careworks Workers Comp|methodology,median_amount|Careworks Workers Comp|Careworks Workers Comp,10th_percentile|Careworks Workers Comp|Careworks Workers Comp,90th_percentile|Careworks Workers Comp|Careworks Workers Comp,count|Careworks Workers Comp|Careworks Workers Comp,additional_payer_notes|Careworks Workers Comp|Careworks Workers Comp,standard_charge|Catholic Hospice|Catholic Hospice|negotiated_dollar,standard_charge|Catholic Hospice|Catholic Hospice|negotiated_percentage,standard_charge|Catholic Hospice|Catholic Hospice|negotiated_algorithm,standard_charge|Catholic Hospice|Catholic Hospice|methodology,median_amount|Catholic Hospice|Catholic Hospice,10th_percentile|Catholic Hospice|Catholic Hospice,90th_percentile|Catholic Hospice|Catholic Hospice,count|Catholic Hospice|Catholic Hospice,additional_payer_notes|Catholic Hospice|Catholic Hospice,standard_charge|Cenpatico Behavioral Health|Cenpatico Behavioral Health|negotiated_dollar,standard_charge|Cenpatico Behavioral Health|Cenpatico Behavioral Health|negotiated_percentage,standard_charge|Cenpatico Behavioral Health|Cenpatico Behavioral Health|negotiated_algorithm,standard_charge|Cenpatico Behavioral Health|Cenpatico Behavioral Health|methodology,median_amount|Cenpatico Behavioral Health|Cenpatico Behavioral Health,10th_percentile|Cenpatico Behavioral Health|Cenpatico Behavioral Health,90th_percentile|Cenpatico Behavioral Health|Cenpatico Behavioral Health,count|Cenpatico Behavioral Health|Cenpatico Behavioral Health,additional_payer_notes|Cenpatico Behavioral Health|Cenpatico Behavioral Health,standard_charge|MSMC|CIGNA|negotiated_dollar,standard_charge|MSMC|CIGNA|negotiated_percentage,standard_charge|MSMC|CIGNA|negotiated_algorithm,standard_charge|MSMC|CIGNA|methodology,median_amount|MSMC|CIGNA,10th_percentile|MSMC|CIGNA,90th_percentile|MSMC|CIGNA,count|MSMC|CIGNA,additional_payer_notes|MSMC|CIGNA,standard_charge|CIGNA Behavioral Health|CIGNA Behavioral Health|negotiated_dollar,standard_charge|CIGNA Behavioral Health|CIGNA Behavioral Health|negotiated_percentage,standard_charge|CIGNA Behavioral Health|CIGNA Behavioral Health|negotiated_algorithm,standard_charge|CIGNA Behavioral Health|CIGNA Behavioral Health|methodology,median_amount|CIGNA Behavioral Health|CIGNA Behavioral Health,10th_percentile|CIGNA Behavioral Health|CIGNA Behavioral Health,90th_percentile|CIGNA Behavioral Health|CIGNA Behavioral Health,count|CIGNA Behavioral Health|CIGNA Behavioral Health,additional_payer_notes|CIGNA Behavioral Health|CIGNA Behavioral Health,standard_charge|Clear Spring Health|Clear Spring Health|negotiated_dollar,standard_charge|Clear Spring Health|Clear Spring Health|negotiated_percentage,standard_charge|Clear Spring Health|Clear Spring Health|negotiated_algorithm,standard_charge|Clear Spring Health|Clear Spring Health|methodology,median_amount|Clear Spring Health|Clear Spring Health,10th_percentile|Clear Spring Health|Clear Spring Health,90th_percentile|Clear Spring Health|Clear Spring Health,count|Clear Spring Health|Clear Spring Health,additional_payer_notes|Clear Spring Health|Clear Spring Health,standard_charge|Concordia Behavioral Health|Concordia Behavioral Health|negotiated_dollar,standard_charge|Concordia Behavioral Health|Concordia Behavioral Health|negotiated_percentage,standard_charge|Concordia Behavioral Health|Concordia Behavioral Health|negotiated_algorithm,standard_charge|Concordia Behavioral Health|Concordia Behavioral Health|methodology,median_amount|Concordia Behavioral Health|Concordia Behavioral Health,10th_percentile|Concordia Behavioral Health|Concordia Behavioral Health,90th_percentile|Concordia Behavioral Health|Concordia Behavioral Health,count|Concordia Behavioral Health|Concordia Behavioral Health,additional_payer_notes|Concordia Behavioral Health|Concordia Behavioral Health,standard_charge|Corvel Healthcare|Corvel Healthcare|negotiated_dollar,standard_charge|Corvel Healthcare|Corvel Healthcare|negotiated_percentage,standard_charge|Corvel Healthcare|Corvel Healthcare|negotiated_algorithm,standard_charge|Corvel Healthcare|Corvel Healthcare|methodology,median_amount|Corvel Healthcare|Corvel Healthcare,10th_percentile|Corvel Healthcare|Corvel Healthcare,90th_percentile|Corvel Healthcare|Corvel Healthcare,count|Corvel Healthcare|Corvel Healthcare,additional_payer_notes|Corvel Healthcare|Corvel Healthcare,standard_charge|Coventry|Coventry|negotiated_dollar,standard_charge|Coventry|Coventry|negotiated_percentage,standard_charge|Coventry|Coventry|negotiated_algorithm,standard_charge|Coventry|Coventry|methodology,median_amount|Coventry|Coventry,10th_percentile|Coventry|Coventry,90th_percentile|Coventry|Coventry,count|Coventry|Coventry,additional_payer_notes|Coventry|Coventry,standard_charge|UnitedHealth Group|COVID19 HRSA UNINSURED|negotiated_dollar,standard_charge|UnitedHealth Group|COVID19 HRSA UNINSURED|negotiated_percentage,standard_charge|UnitedHealth Group|COVID19 HRSA UNINSURED|negotiated_algorithm,standard_charge|UnitedHealth Group|COVID19 HRSA UNINSURED|methodology,median_amount|UnitedHealth Group|COVID19 HRSA UNINSURED,10th_percentile|UnitedHealth Group|COVID19 HRSA UNINSURED,90th_percentile|UnitedHealth Group|COVID19 HRSA UNINSURED,count|UnitedHealth Group|COVID19 HRSA UNINSURED,additional_payer_notes|UnitedHealth Group|COVID19 HRSA UNINSURED,standard_charge|Devoted Health|Devoted Health Medicare HMO|negotiated_dollar,standard_charge|Devoted Health|Devoted Health Medicare HMO|negotiated_percentage,standard_charge|Devoted Health|Devoted Health Medicare HMO|negotiated_algorithm,standard_charge|Devoted Health|Devoted Health Medicare HMO|methodology,median_amount|Devoted Health|Devoted Health Medicare HMO,10th_percentile|Devoted Health|Devoted Health Medicare HMO,90th_percentile|Devoted Health|Devoted Health Medicare HMO,count|Devoted Health|Devoted Health Medicare HMO,additional_payer_notes|Devoted Health|Devoted Health Medicare HMO,standard_charge|Dimension Health|Dimension|negotiated_dollar,standard_charge|Dimension Health|Dimension|negotiated_percentage,standard_charge|Dimension Health|Dimension|negotiated_algorithm,standard_charge|Dimension Health|Dimension|methodology,median_amount|Dimension Health|Dimension,10th_percentile|Dimension Health|Dimension,90th_percentile|Dimension Health|Dimension,count|Dimension Health|Dimension,additional_payer_notes|Dimension Health|Dimension,standard_charge|Dimension Health|Dimension International|negotiated_dollar,standard_charge|Dimension Health|Dimension International|negotiated_percentage,standard_charge|Dimension Health|Dimension International|negotiated_algorithm,standard_charge|Dimension Health|Dimension International|methodology,median_amount|Dimension Health|Dimension International,10th_percentile|Dimension Health|Dimension International,90th_percentile|Dimension Health|Dimension International,count|Dimension Health|Dimension International,additional_payer_notes|Dimension Health|Dimension International,standard_charge|Dimension Health|Dimension Plus|negotiated_dollar,standard_charge|Dimension Health|Dimension Plus|negotiated_percentage,standard_charge|Dimension Health|Dimension Plus|negotiated_algorithm,standard_charge|Dimension Health|Dimension Plus|methodology,median_amount|Dimension Health|Dimension Plus,10th_percentile|Dimension Health|Dimension Plus,90th_percentile|Dimension Health|Dimension Plus,count|Dimension Health|Dimension Plus,additional_payer_notes|Dimension Health|Dimension Plus,standard_charge|Doctors Healthcare|Doctors Healthcare Medicare HMO|negotiated_dollar,standard_charge|Doctors Healthcare|Doctors Healthcare Medicare HMO|negotiated_percentage,standard_charge|Doctors Healthcare|Doctors Healthcare Medicare HMO|negotiated_algorithm,standard_charge|Doctors Healthcare|Doctors Healthcare Medicare HMO|methodology,median_amount|Doctors Healthcare|Doctors Healthcare Medicare HMO,10th_percentile|Doctors Healthcare|Doctors Healthcare Medicare HMO,90th_percentile|Doctors Healthcare|Doctors Healthcare Medicare HMO,count|Doctors Healthcare|Doctors Healthcare Medicare HMO,additional_payer_notes|Doctors Healthcare|Doctors Healthcare Medicare HMO,standard_charge|First Health Network|First Health|negotiated_dollar,standard_charge|First Health Network|First Health|negotiated_percentage,standard_charge|First Health Network|First Health|negotiated_algorithm,standard_charge|First Health Network|First Health|methodology,median_amount|First Health Network|First Health,10th_percentile|First Health Network|First Health,90th_percentile|First Health Network|First Health,count|First Health Network|First Health,additional_payer_notes|First Health Network|First Health,standard_charge|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare|negotiated_dollar,standard_charge|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare|negotiated_percentage,standard_charge|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare|negotiated_algorithm,standard_charge|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare|methodology,median_amount|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare,10th_percentile|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare,90th_percentile|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare,count|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare,additional_payer_notes|Florida Healthcare Plus Medicare|Florida Healthcare Plus Medicare,standard_charge|GEHA PCIP|GEHA PCIP|negotiated_dollar,standard_charge|GEHA PCIP|GEHA PCIP|negotiated_percentage,standard_charge|GEHA PCIP|GEHA PCIP|negotiated_algorithm,standard_charge|GEHA PCIP|GEHA PCIP|methodology,median_amount|GEHA PCIP|GEHA PCIP,10th_percentile|GEHA PCIP|GEHA PCIP,90th_percentile|GEHA PCIP|GEHA PCIP,count|GEHA PCIP|GEHA PCIP,additional_payer_notes|GEHA PCIP|GEHA PCIP,standard_charge|Health Sun Health Plans|Health Sun Health Plans|negotiated_dollar,standard_charge|Health Sun Health Plans|Health Sun Health Plans|negotiated_percentage,standard_charge|Health Sun Health Plans|Health Sun Health Plans|negotiated_algorithm,standard_charge|Health Sun Health Plans|Health Sun Health Plans|methodology,median_amount|Health Sun Health Plans|Health Sun Health Plans,10th_percentile|Health Sun Health Plans|Health Sun Health Plans,90th_percentile|Health Sun Health Plans|Health Sun Health Plans,count|Health Sun Health Plans|Health Sun Health Plans,additional_payer_notes|Health Sun Health Plans|Health Sun Health Plans,standard_charge|Healthnet VA Choice|Healthnet VA Choice|negotiated_dollar,standard_charge|Healthnet VA Choice|Healthnet VA Choice|negotiated_percentage,standard_charge|Healthnet VA Choice|Healthnet VA Choice|negotiated_algorithm,standard_charge|Healthnet VA Choice|Healthnet VA Choice|methodology,median_amount|Healthnet VA Choice|Healthnet VA Choice,10th_percentile|Healthnet VA Choice|Healthnet VA Choice,90th_percentile|Healthnet VA Choice|Healthnet VA Choice,count|Healthnet VA Choice|Healthnet VA Choice,additional_payer_notes|Healthnet VA Choice|Healthnet VA Choice,standard_charge|Humana|Humana|negotiated_dollar,standard_charge|Humana|Humana|negotiated_percentage,standard_charge|Humana|Humana|negotiated_algorithm,standard_charge|Humana|Humana|methodology,median_amount|Humana|Humana,10th_percentile|Humana|Humana,90th_percentile|Humana|Humana,count|Humana|Humana,additional_payer_notes|Humana|Humana,standard_charge|Humana Behavioral Health|Humana Behavioral Health|negotiated_dollar,standard_charge|Humana Behavioral Health|Humana Behavioral Health|negotiated_percentage,standard_charge|Humana Behavioral Health|Humana Behavioral Health|negotiated_algorithm,standard_charge|Humana Behavioral Health|Humana Behavioral Health|methodology,median_amount|Humana Behavioral Health|Humana Behavioral Health,10th_percentile|Humana Behavioral Health|Humana Behavioral Health,90th_percentile|Humana Behavioral Health|Humana Behavioral Health,count|Humana Behavioral Health|Humana Behavioral Health,additional_payer_notes|Humana Behavioral Health|Humana Behavioral Health,standard_charge|Humana Behavioral Health|Humana Behavioral Health Medicare|negotiated_dollar,standard_charge|Humana Behavioral Health|Humana Behavioral Health Medicare|negotiated_percentage,standard_charge|Humana Behavioral Health|Humana Behavioral Health Medicare|negotiated_algorithm,standard_charge|Humana Behavioral Health|Humana Behavioral Health Medicare|methodology,median_amount|Humana Behavioral Health|Humana Behavioral Health Medicare,10th_percentile|Humana Behavioral Health|Humana Behavioral Health Medicare,90th_percentile|Humana Behavioral Health|Humana Behavioral Health Medicare,count|Humana Behavioral Health|Humana Behavioral Health Medicare,additional_payer_notes|Humana Behavioral Health|Humana Behavioral Health Medicare,standard_charge|Humana|Humana HUMx|negotiated_dollar,standard_charge|Humana|Humana HUMx|negotiated_percentage,standard_charge|Humana|Humana HUMx|negotiated_algorithm,standard_charge|Humana|Humana HUMx|methodology,median_amount|Humana|Humana HUMx,10th_percentile|Humana|Humana HUMx,90th_percentile|Humana|Humana HUMx,count|Humana|Humana HUMx,additional_payer_notes|Humana|Humana HUMx,standard_charge|Leon Health Plans|Leon Health Plans|negotiated_dollar,standard_charge|Leon Health Plans|Leon Health Plans|negotiated_percentage,standard_charge|Leon Health Plans|Leon Health Plans|negotiated_algorithm,standard_charge|Leon Health Plans|Leon Health Plans|methodology,median_amount|Leon Health Plans|Leon Health Plans,10th_percentile|Leon Health Plans|Leon Health Plans,90th_percentile|Leon Health Plans|Leon Health Plans,count|Leon Health Plans|Leon Health Plans,additional_payer_notes|Leon Health Plans|Leon Health Plans,standard_charge|Leon Medical Center|Leon Medical Center|negotiated_dollar,standard_charge|Leon Medical Center|Leon Medical Center|negotiated_percentage,standard_charge|Leon Medical Center|Leon Medical Center|negotiated_algorithm,standard_charge|Leon Medical Center|Leon Medical Center|methodology,median_amount|Leon Medical Center|Leon Medical Center,10th_percentile|Leon Medical Center|Leon Medical Center,90th_percentile|Leon Medical Center|Leon Medical Center,count|Leon Medical Center|Leon Medical Center,additional_payer_notes|Leon Medical Center|Leon Medical Center,standard_charge|Longevity Health Medicare HMO|Longevity Health Medicare HMO|negotiated_dollar,standard_charge|Longevity Health Medicare HMO|Longevity Health Medicare HMO|negotiated_percentage,standard_charge|Longevity Health Medicare HMO|Longevity Health Medicare HMO|negotiated_algorithm,standard_charge|Longevity Health Medicare HMO|Longevity Health Medicare HMO|methodology,median_amount|Longevity Health Medicare HMO|Longevity Health Medicare HMO,10th_percentile|Longevity Health Medicare HMO|Longevity Health Medicare HMO,90th_percentile|Longevity Health Medicare HMO|Longevity Health Medicare HMO,count|Longevity Health Medicare HMO|Longevity Health Medicare HMO,additional_payer_notes|Longevity Health Medicare HMO|Longevity Health Medicare HMO,standard_charge|Magellan Behavioral Health|Magellan Behavioral Health|negotiated_dollar,standard_charge|Magellan Behavioral Health|Magellan Behavioral Health|negotiated_percentage,standard_charge|Magellan Behavioral Health|Magellan Behavioral Health|negotiated_algorithm,standard_charge|Magellan Behavioral Health|Magellan Behavioral Health|methodology,median_amount|Magellan Behavioral Health|Magellan Behavioral Health,10th_percentile|Magellan Behavioral Health|Magellan Behavioral Health,90th_percentile|Magellan Behavioral Health|Magellan Behavioral Health,count|Magellan Behavioral Health|Magellan Behavioral Health,additional_payer_notes|Magellan Behavioral Health|Magellan Behavioral Health,standard_charge|Magellan Complete Care|Magellan Complete Care|negotiated_dollar,standard_charge|Magellan Complete Care|Magellan Complete Care|negotiated_percentage,standard_charge|Magellan Complete Care|Magellan Complete Care|negotiated_algorithm,standard_charge|Magellan Complete Care|Magellan Complete Care|methodology,median_amount|Magellan Complete Care|Magellan Complete Care,10th_percentile|Magellan Complete Care|Magellan Complete Care,90th_percentile|Magellan Complete Care|Magellan Complete Care,count|Magellan Complete Care|Magellan Complete Care,additional_payer_notes|Magellan Complete Care|Magellan Complete Care,standard_charge|Medicaid|Medicaid|negotiated_dollar,standard_charge|Medicaid|Medicaid|negotiated_percentage,standard_charge|Medicaid|Medicaid|negotiated_algorithm,standard_charge|Medicaid|Medicaid|methodology,median_amount|Medicaid|Medicaid,10th_percentile|Medicaid|Medicaid,90th_percentile|Medicaid|Medicaid,count|Medicaid|Medicaid,additional_payer_notes|Medicaid|Medicaid,standard_charge|Medicaid HMO APR DRG|Medicaid HMO APR DRG|negotiated_dollar,standard_charge|Medicaid HMO APR DRG|Medicaid HMO APR DRG|negotiated_percentage,standard_charge|Medicaid HMO APR DRG|Medicaid HMO APR DRG|negotiated_algorithm,standard_charge|Medicaid HMO APR DRG|Medicaid HMO APR DRG|methodology,median_amount|Medicaid HMO APR DRG|Medicaid HMO APR DRG,10th_percentile|Medicaid HMO APR DRG|Medicaid HMO APR DRG,90th_percentile|Medicaid HMO APR DRG|Medicaid HMO APR DRG,count|Medicaid HMO APR DRG|Medicaid HMO APR DRG,additional_payer_notes|Medicaid HMO APR DRG|Medicaid HMO APR DRG,standard_charge|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG|negotiated_dollar,standard_charge|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG|negotiated_percentage,standard_charge|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG|negotiated_algorithm,standard_charge|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG|methodology,median_amount|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG,10th_percentile|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG,90th_percentile|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG,count|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG,additional_payer_notes|Medicaid HMO APR EAPG|Medicaid HMO APR EAPG,standard_charge|Medicare|Medicare|negotiated_dollar,standard_charge|Medicare|Medicare|negotiated_percentage,standard_charge|Medicare|Medicare|negotiated_algorithm,standard_charge|Medicare|Medicare|methodology,median_amount|Medicare|Medicare,10th_percentile|Medicare|Medicare,90th_percentile|Medicare|Medicare,count|Medicare|Medicare,additional_payer_notes|Medicare|Medicare,standard_charge|Medicare HMO|Medicare HMO|negotiated_dollar,standard_charge|Medicare HMO|Medicare HMO|negotiated_percentage,standard_charge|Medicare HMO|Medicare HMO|negotiated_algorithm,standard_charge|Medicare HMO|Medicare HMO|methodology,median_amount|Medicare HMO|Medicare HMO,10th_percentile|Medicare HMO|Medicare HMO,90th_percentile|Medicare HMO|Medicare HMO,count|Medicare HMO|Medicare HMO,additional_payer_notes|Medicare HMO|Medicare HMO,standard_charge|Mental Health Associates|Mental Health Associates|negotiated_dollar,standard_charge|Mental Health Associates|Mental Health Associates|negotiated_percentage,standard_charge|Mental Health Associates|Mental Health Associates|negotiated_algorithm,standard_charge|Mental Health Associates|Mental Health Associates|methodology,median_amount|Mental Health Associates|Mental Health Associates,10th_percentile|Mental Health Associates|Mental Health Associates,90th_percentile|Mental Health Associates|Mental Health Associates,count|Mental Health Associates|Mental Health Associates,additional_payer_notes|Mental Health Associates|Mental Health Associates,standard_charge|Miscellaneous Insurances|Miscellaneous Insurances|negotiated_dollar,standard_charge|Miscellaneous Insurances|Miscellaneous Insurances|negotiated_percentage,standard_charge|Miscellaneous Insurances|Miscellaneous Insurances|negotiated_algorithm,standard_charge|Miscellaneous Insurances|Miscellaneous Insurances|methodology,median_amount|Miscellaneous Insurances|Miscellaneous Insurances,10th_percentile|Miscellaneous Insurances|Miscellaneous Insurances,90th_percentile|Miscellaneous Insurances|Miscellaneous Insurances,count|Miscellaneous Insurances|Miscellaneous Insurances,additional_payer_notes|Miscellaneous Insurances|Miscellaneous Insurances,standard_charge|MMM of Florida|MMM of FL Medicare HMO|negotiated_dollar,standard_charge|MMM of Florida|MMM of FL Medicare HMO|negotiated_percentage,standard_charge|MMM of Florida|MMM of FL Medicare HMO|negotiated_algorithm,standard_charge|MMM of Florida|MMM of FL Medicare HMO|methodology,median_amount|MMM of Florida|MMM of FL Medicare HMO,10th_percentile|MMM of Florida|MMM of FL Medicare HMO,90th_percentile|MMM of Florida|MMM of FL Medicare HMO,count|MMM of Florida|MMM of FL Medicare HMO,additional_payer_notes|MMM of Florida|MMM of FL Medicare HMO,standard_charge|Molina Healthcare of Florida|Molina HIE|negotiated_dollar,standard_charge|Molina Healthcare of Florida|Molina HIE|negotiated_percentage,standard_charge|Molina Healthcare of Florida|Molina HIE|negotiated_algorithm,standard_charge|Molina Healthcare of Florida|Molina HIE|methodology,median_amount|Molina Healthcare of Florida|Molina HIE,10th_percentile|Molina Healthcare of Florida|Molina HIE,90th_percentile|Molina Healthcare of Florida|Molina HIE,count|Molina Healthcare of Florida|Molina HIE,additional_payer_notes|Molina Healthcare of Florida|Molina HIE,standard_charge|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE|negotiated_dollar,standard_charge|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE|negotiated_percentage,standard_charge|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE|negotiated_algorithm,standard_charge|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE|methodology,median_amount|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE,10th_percentile|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE,90th_percentile|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE,count|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE,additional_payer_notes|Mount Sinai Eldercare PACE|Mount Sinai Eldercare PACE,standard_charge|Multiplan|Multiplan|negotiated_dollar,standard_charge|Multiplan|Multiplan|negotiated_percentage,standard_charge|Multiplan|Multiplan|negotiated_algorithm,standard_charge|Multiplan|Multiplan|methodology,median_amount|Multiplan|Multiplan,10th_percentile|Multiplan|Multiplan,90th_percentile|Multiplan|Multiplan,count|Multiplan|Multiplan,additional_payer_notes|Multiplan|Multiplan,standard_charge|NCH Management Systems|NCH Careplus Medicare|negotiated_dollar,standard_charge|NCH Management Systems|NCH Careplus Medicare|negotiated_percentage,standard_charge|NCH Management Systems|NCH Careplus Medicare|negotiated_algorithm,standard_charge|NCH Management Systems|NCH Careplus Medicare|methodology,median_amount|NCH Management Systems|NCH Careplus Medicare,10th_percentile|NCH Management Systems|NCH Careplus Medicare,90th_percentile|NCH Management Systems|NCH Careplus Medicare,count|NCH Management Systems|NCH Careplus Medicare,additional_payer_notes|NCH Management Systems|NCH Careplus Medicare,standard_charge|NCH Management Systems|NCH Careplus Medicare Rad Onc|negotiated_dollar,standard_charge|NCH Management Systems|NCH Careplus Medicare Rad Onc|negotiated_percentage,standard_charge|NCH Management Systems|NCH Careplus Medicare Rad Onc|negotiated_algorithm,standard_charge|NCH Management Systems|NCH Careplus Medicare Rad Onc|methodology,median_amount|NCH Management Systems|NCH Careplus Medicare Rad Onc,10th_percentile|NCH Management Systems|NCH Careplus Medicare Rad Onc,90th_percentile|NCH Management Systems|NCH Careplus Medicare Rad Onc,count|NCH Management Systems|NCH Careplus Medicare Rad Onc,additional_payer_notes|NCH Management Systems|NCH Careplus Medicare Rad Onc,standard_charge|NCH Management Systems|NCH Coventry Medicare|negotiated_dollar,standard_charge|NCH Management Systems|NCH Coventry Medicare|negotiated_percentage,standard_charge|NCH Management Systems|NCH Coventry Medicare|negotiated_algorithm,standard_charge|NCH Management Systems|NCH Coventry Medicare|methodology,median_amount|NCH Management Systems|NCH Coventry Medicare,10th_percentile|NCH Management Systems|NCH Coventry Medicare,90th_percentile|NCH Management Systems|NCH Coventry Medicare,count|NCH Management Systems|NCH Coventry Medicare,additional_payer_notes|NCH Management Systems|NCH Coventry Medicare,standard_charge|NCH Management Systems|NCH Coventry Medicare Rad Onc|negotiated_dollar,standard_charge|NCH Management Systems|NCH Coventry Medicare Rad Onc|negotiated_percentage,standard_charge|NCH Management Systems|NCH Coventry Medicare Rad Onc|negotiated_algorithm,standard_charge|NCH Management Systems|NCH Coventry Medicare Rad Onc|methodology,median_amount|NCH Management Systems|NCH Coventry Medicare Rad Onc,10th_percentile|NCH Management Systems|NCH Coventry Medicare Rad Onc,90th_percentile|NCH Management Systems|NCH Coventry Medicare Rad Onc,count|NCH Management Systems|NCH Coventry Medicare Rad Onc,additional_payer_notes|NCH Management Systems|NCH Coventry Medicare Rad Onc,standard_charge|NCH Devoted Medicare|NCH Devoted Medicare Med Onc|negotiated_dollar,standard_charge|NCH Devoted Medicare|NCH Devoted Medicare Med Onc|negotiated_percentage,standard_charge|NCH Devoted Medicare|NCH Devoted Medicare Med Onc|negotiated_algorithm,standard_charge|NCH Devoted Medicare|NCH Devoted Medicare Med Onc|methodology,median_amount|NCH Devoted Medicare|NCH Devoted Medicare Med Onc,10th_percentile|NCH Devoted Medicare|NCH Devoted Medicare Med Onc,90th_percentile|NCH Devoted Medicare|NCH Devoted Medicare Med Onc,count|NCH Devoted Medicare|NCH Devoted Medicare Med Onc,additional_payer_notes|NCH Devoted Medicare|NCH Devoted Medicare Med Onc,standard_charge|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc|negotiated_dollar,standard_charge|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc|negotiated_percentage,standard_charge|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc|negotiated_algorithm,standard_charge|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc|methodology,median_amount|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc,10th_percentile|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc,90th_percentile|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc,count|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc,additional_payer_notes|NCH Devoted Medicare|NCH Devoted Medicare Rad Onc,standard_charge||NCH Healthsun Medicare Rad Onc|negotiated_dollar,standard_charge||NCH Healthsun Medicare Rad Onc|negotiated_percentage,standard_charge||NCH Healthsun Medicare Rad Onc|negotiated_algorithm,standard_charge||NCH Healthsun Medicare Rad Onc|methodology,median_amount||NCH Healthsun Medicare Rad Onc,10th_percentile||NCH Healthsun Medicare Rad Onc,90th_percentile||NCH Healthsun Medicare Rad Onc,count||NCH Healthsun Medicare Rad Onc,additional_payer_notes||NCH Healthsun Medicare Rad Onc,standard_charge|NCH Management Systems|NCH Humana Medicare|negotiated_dollar,standard_charge|NCH Management Systems|NCH Humana Medicare|negotiated_percentage,standard_charge|NCH Management Systems|NCH Humana Medicare|negotiated_algorithm,standard_charge|NCH Management Systems|NCH Humana Medicare|methodology,median_amount|NCH Management Systems|NCH Humana Medicare,10th_percentile|NCH Management Systems|NCH Humana Medicare,90th_percentile|NCH Management Systems|NCH Humana Medicare,count|NCH Management Systems|NCH Humana Medicare,additional_payer_notes|NCH Management Systems|NCH Humana Medicare,standard_charge|NCH Management Systems|NCH Humana Medicare Rad Onc|negotiated_dollar,standard_charge|NCH Management Systems|NCH Humana Medicare Rad Onc|negotiated_percentage,standard_charge|NCH Management Systems|NCH Humana Medicare Rad Onc|negotiated_algorithm,standard_charge|NCH Management Systems|NCH Humana Medicare Rad Onc|methodology,median_amount|NCH Management Systems|NCH Humana Medicare Rad Onc,10th_percentile|NCH Management Systems|NCH Humana Medicare Rad Onc,90th_percentile|NCH Management Systems|NCH Humana Medicare Rad Onc,count|NCH Management Systems|NCH Humana Medicare Rad Onc,additional_payer_notes|NCH Management Systems|NCH Humana Medicare Rad Onc,standard_charge|NCH Management Systems|NCH Simply Medicare|negotiated_dollar,standard_charge|NCH Management Systems|NCH Simply Medicare|negotiated_percentage,standard_charge|NCH Management Systems|NCH Simply Medicare|negotiated_algorithm,standard_charge|NCH Management Systems|NCH Simply Medicare|methodology,median_amount|NCH Management Systems|NCH Simply Medicare,10th_percentile|NCH Management Systems|NCH Simply Medicare,90th_percentile|NCH Management Systems|NCH Simply Medicare,count|NCH Management Systems|NCH Simply Medicare,additional_payer_notes|NCH Management Systems|NCH Simply Medicare,standard_charge|NCH Management Systems|NCH Simply Medicare Rad Onc|negotiated_dollar,standard_charge|NCH Management Systems|NCH Simply Medicare Rad Onc|negotiated_percentage,standard_charge|NCH Management Systems|NCH Simply Medicare Rad Onc|negotiated_algorithm,standard_charge|NCH Management Systems|NCH Simply Medicare Rad Onc|methodology,median_amount|NCH Management Systems|NCH Simply Medicare Rad Onc,10th_percentile|NCH Management Systems|NCH Simply Medicare Rad Onc,90th_percentile|NCH Management Systems|NCH Simply Medicare Rad Onc,count|NCH Management Systems|NCH Simply Medicare Rad Onc,additional_payer_notes|NCH Management Systems|NCH Simply Medicare Rad Onc,standard_charge|New Directions Behavioral Health|New Directions Behavioral Health|negotiated_dollar,standard_charge|New Directions Behavioral Health|New Directions Behavioral Health|negotiated_percentage,standard_charge|New Directions Behavioral Health|New Directions Behavioral Health|negotiated_algorithm,standard_charge|New Directions Behavioral Health|New Directions Behavioral Health|methodology,median_amount|New Directions Behavioral Health|New Directions Behavioral Health,10th_percentile|New Directions Behavioral Health|New Directions Behavioral Health,90th_percentile|New Directions Behavioral Health|New Directions Behavioral Health,count|New Directions Behavioral Health|New Directions Behavioral Health,additional_payer_notes|New Directions Behavioral Health|New Directions Behavioral Health,standard_charge|Oscar Health (HIE)|Oscar Health (HIE)|negotiated_dollar,standard_charge|Oscar Health (HIE)|Oscar Health (HIE)|negotiated_percentage,standard_charge|Oscar Health (HIE)|Oscar Health (HIE)|negotiated_algorithm,standard_charge|Oscar Health (HIE)|Oscar Health (HIE)|methodology,median_amount|Oscar Health (HIE)|Oscar Health (HIE),10th_percentile|Oscar Health (HIE)|Oscar Health (HIE),90th_percentile|Oscar Health (HIE)|Oscar Health (HIE),count|Oscar Health (HIE)|Oscar Health (HIE),additional_payer_notes|Oscar Health (HIE)|Oscar Health (HIE),standard_charge|Florida Pace Centers|Pace|negotiated_dollar,standard_charge|Florida Pace Centers|Pace|negotiated_percentage,standard_charge|Florida Pace Centers|Pace|negotiated_algorithm,standard_charge|Florida Pace Centers|Pace|methodology,median_amount|Florida Pace Centers|Pace,10th_percentile|Florida Pace Centers|Pace,90th_percentile|Florida Pace Centers|Pace,count|Florida Pace Centers|Pace,additional_payer_notes|Florida Pace Centers|Pace,standard_charge|Positive Healthcare|Positive Healthcare Medicaid|negotiated_dollar,standard_charge|Positive Healthcare|Positive Healthcare Medicaid|negotiated_percentage,standard_charge|Positive Healthcare|Positive Healthcare Medicaid|negotiated_algorithm,standard_charge|Positive Healthcare|Positive Healthcare Medicaid|methodology,median_amount|Positive Healthcare|Positive Healthcare Medicaid,10th_percentile|Positive Healthcare|Positive Healthcare Medicaid,90th_percentile|Positive Healthcare|Positive Healthcare Medicaid,count|Positive Healthcare|Positive Healthcare Medicaid,additional_payer_notes|Positive Healthcare|Positive Healthcare Medicaid,standard_charge|Positive Healthcare of Florida|Positive Healthcare of Florida|negotiated_dollar,standard_charge|Positive Healthcare of Florida|Positive Healthcare of Florida|negotiated_percentage,standard_charge|Positive Healthcare of Florida|Positive Healthcare of Florida|negotiated_algorithm,standard_charge|Positive Healthcare of Florida|Positive Healthcare of Florida|methodology,median_amount|Positive Healthcare of Florida|Positive Healthcare of Florida,10th_percentile|Positive Healthcare of Florida|Positive Healthcare of Florida,90th_percentile|Positive Healthcare of Florida|Positive Healthcare of Florida,count|Positive Healthcare of Florida|Positive Healthcare of Florida,additional_payer_notes|Positive Healthcare of Florida|Positive Healthcare of Florida,standard_charge|Prestige Health Choice|Prestige Health Choice|negotiated_dollar,standard_charge|Prestige Health Choice|Prestige Health Choice|negotiated_percentage,standard_charge|Prestige Health Choice|Prestige Health Choice|negotiated_algorithm,standard_charge|Prestige Health Choice|Prestige Health Choice|methodology,median_amount|Prestige Health Choice|Prestige Health Choice,10th_percentile|Prestige Health Choice|Prestige Health Choice,90th_percentile|Prestige Health Choice|Prestige Health Choice,count|Prestige Health Choice|Prestige Health Choice,additional_payer_notes|Prestige Health Choice|Prestige Health Choice,standard_charge|Seasons Hospice|Seasons Hospice|negotiated_dollar,standard_charge|Seasons Hospice|Seasons Hospice|negotiated_percentage,standard_charge|Seasons Hospice|Seasons Hospice|negotiated_algorithm,standard_charge|Seasons Hospice|Seasons Hospice|methodology,median_amount|Seasons Hospice|Seasons Hospice,10th_percentile|Seasons Hospice|Seasons Hospice,90th_percentile|Seasons Hospice|Seasons Hospice,count|Seasons Hospice|Seasons Hospice,additional_payer_notes|Seasons Hospice|Seasons Hospice,standard_charge|Simply Healthcare Plan|Simply Healthcare Medicare|negotiated_dollar,standard_charge|Simply Healthcare Plan|Simply Healthcare Medicare|negotiated_percentage,standard_charge|Simply Healthcare Plan|Simply Healthcare Medicare|negotiated_algorithm,standard_charge|Simply Healthcare Plan|Simply Healthcare Medicare|methodology,median_amount|Simply Healthcare Plan|Simply Healthcare Medicare,10th_percentile|Simply Healthcare Plan|Simply Healthcare Medicare,90th_percentile|Simply Healthcare Plan|Simply Healthcare Medicare,count|Simply Healthcare Plan|Simply Healthcare Medicare,additional_payer_notes|Simply Healthcare Plan|Simply Healthcare Medicare,standard_charge|Simply Healthcare Plan|Simply Medicaid|negotiated_dollar,standard_charge|Simply Healthcare Plan|Simply Medicaid|negotiated_percentage,standard_charge|Simply Healthcare Plan|Simply Medicaid|negotiated_algorithm,standard_charge|Simply Healthcare Plan|Simply Medicaid|methodology,median_amount|Simply Healthcare Plan|Simply Medicaid,10th_percentile|Simply Healthcare Plan|Simply Medicaid,90th_percentile|Simply Healthcare Plan|Simply Medicaid,count|Simply Healthcare Plan|Simply Medicaid,additional_payer_notes|Simply Healthcare Plan|Simply Medicaid,standard_charge|Solis Health|Solis Health Medicare HMO|negotiated_dollar,standard_charge|Solis Health|Solis Health Medicare HMO|negotiated_percentage,standard_charge|Solis Health|Solis Health Medicare HMO|negotiated_algorithm,standard_charge|Solis Health|Solis Health Medicare HMO|methodology,median_amount|Solis Health|Solis Health Medicare HMO,10th_percentile|Solis Health|Solis Health Medicare HMO,90th_percentile|Solis Health|Solis Health Medicare HMO,count|Solis Health|Solis Health Medicare HMO,additional_payer_notes|Solis Health|Solis Health Medicare HMO,standard_charge|Sunshine Medicaid|Sunshine Medicaid|negotiated_dollar,standard_charge|Sunshine Medicaid|Sunshine Medicaid|negotiated_percentage,standard_charge|Sunshine Medicaid|Sunshine Medicaid|negotiated_algorithm,standard_charge|Sunshine Medicaid|Sunshine Medicaid|methodology,median_amount|Sunshine Medicaid|Sunshine Medicaid,10th_percentile|Sunshine Medicaid|Sunshine Medicaid,90th_percentile|Sunshine Medicaid|Sunshine Medicaid,count|Sunshine Medicaid|Sunshine Medicaid,additional_payer_notes|Sunshine Medicaid|Sunshine Medicaid,standard_charge|TriCare|TriCare|negotiated_dollar,standard_charge|TriCare|TriCare|negotiated_percentage,standard_charge|TriCare|TriCare|negotiated_algorithm,standard_charge|TriCare|TriCare|methodology,median_amount|TriCare|TriCare,10th_percentile|TriCare|TriCare,90th_percentile|TriCare|TriCare,count|TriCare|TriCare,additional_payer_notes|TriCare|TriCare,standard_charge|United Healthcare|United Behavioral|negotiated_dollar,standard_charge|United Healthcare|United Behavioral|negotiated_percentage,standard_charge|United Healthcare|United Behavioral|negotiated_algorithm,standard_charge|United Healthcare|United Behavioral|methodology,median_amount|United Healthcare|United Behavioral,10th_percentile|United Healthcare|United Behavioral,90th_percentile|United Healthcare|United Behavioral,count|United Healthcare|United Behavioral,additional_payer_notes|United Healthcare|United Behavioral,standard_charge|United Healthcare|United Behavioral Medicaid|negotiated_dollar,standard_charge|United Healthcare|United Behavioral Medicaid|negotiated_percentage,standard_charge|United Healthcare|United Behavioral Medicaid|negotiated_algorithm,standard_charge|United Healthcare|United Behavioral Medicaid|methodology,median_amount|United Healthcare|United Behavioral Medicaid,10th_percentile|United Healthcare|United Behavioral Medicaid,90th_percentile|United Healthcare|United Behavioral Medicaid,count|United Healthcare|United Behavioral Medicaid,additional_payer_notes|United Healthcare|United Behavioral Medicaid,standard_charge|United Healthcare|United Behavioral Medicare|negotiated_dollar,standard_charge|United Healthcare|United Behavioral Medicare|negotiated_percentage,standard_charge|United Healthcare|United Behavioral Medicare|negotiated_algorithm,standard_charge|United Healthcare|United Behavioral Medicare|methodology,median_amount|United Healthcare|United Behavioral Medicare,10th_percentile|United Healthcare|United Behavioral Medicare,90th_percentile|United Healthcare|United Behavioral Medicare,count|United Healthcare|United Behavioral Medicare,additional_payer_notes|United Healthcare|United Behavioral Medicare,standard_charge|United HealthCare|United HealthCare|negotiated_dollar,standard_charge|United HealthCare|United HealthCare|negotiated_percentage,standard_charge|United HealthCare|United HealthCare|negotiated_algorithm,standard_charge|United HealthCare|United HealthCare|methodology,median_amount|United HealthCare|United HealthCare,10th_percentile|United HealthCare|United HealthCare,90th_percentile|United HealthCare|United HealthCare,count|United HealthCare|United HealthCare,additional_payer_notes|United HealthCare|United HealthCare,standard_charge|United HealthCare|United Medicare HMO|negotiated_dollar,standard_charge|United HealthCare|United Medicare HMO|negotiated_percentage,standard_charge|United HealthCare|United Medicare HMO|negotiated_algorithm,standard_charge|United HealthCare|United Medicare HMO|methodology,median_amount|United HealthCare|United Medicare HMO,10th_percentile|United HealthCare|United Medicare HMO,90th_percentile|United HealthCare|United Medicare HMO,count|United HealthCare|United Medicare HMO,additional_payer_notes|United HealthCare|United Medicare HMO,standard_charge|United HealthCare|United Options PPO|negotiated_dollar,standard_charge|United HealthCare|United Options PPO|negotiated_percentage,standard_charge|United HealthCare|United Options PPO|negotiated_algorithm,standard_charge|United HealthCare|United Options PPO|methodology,median_amount|United HealthCare|United Options PPO,10th_percentile|United HealthCare|United Options PPO,90th_percentile|United HealthCare|United Options PPO,count|United HealthCare|United Options PPO,additional_payer_notes|United HealthCare|United Options PPO,standard_charge|University of Miami Behavioral Health|University of Miami Behavioral Health|negotiated_dollar,standard_charge|University of Miami Behavioral Health|University of Miami Behavioral Health|negotiated_percentage,standard_charge|University of Miami Behavioral Health|University of Miami Behavioral Health|negotiated_algorithm,standard_charge|University of Miami Behavioral Health|University of Miami Behavioral Health|methodology,median_amount|University of Miami Behavioral Health|University of Miami Behavioral Health,10th_percentile|University of Miami Behavioral Health|University of Miami Behavioral Health,90th_percentile|University of Miami Behavioral Health|University of Miami Behavioral Health,count|University of Miami Behavioral Health|University of Miami Behavioral Health,additional_payer_notes|University of Miami Behavioral Health|University of Miami Behavioral Health,standard_charge|Value Options|Value Options Behavioral Health|negotiated_dollar,standard_charge|Value Options|Value Options Behavioral Health|negotiated_percentage,standard_charge|Value Options|Value Options Behavioral Health|negotiated_algorithm,standard_charge|Value Options|Value Options Behavioral Health|methodology,median_amount|Value Options|Value Options Behavioral Health,10th_percentile|Value Options|Value Options Behavioral Health,90th_percentile|Value Options|Value Options Behavioral Health,count|Value Options|Value Options Behavioral Health,additional_payer_notes|Value Options|Value Options Behavioral Health,standard_charge|Veterans Health Administration|Veterans Health Administration|negotiated_dollar,standard_charge|Veterans Health Administration|Veterans Health Administration|negotiated_percentage,standard_charge|Veterans Health Administration|Veterans Health Administration|negotiated_algorithm,standard_charge|Veterans Health Administration|Veterans Health Administration|methodology,median_amount|Veterans Health Administration|Veterans Health Administration,10th_percentile|Veterans Health Administration|Veterans Health Administration,90th_percentile|Veterans Health Administration|Veterans Health Administration,count|Veterans Health Administration|Veterans Health Administration,additional_payer_notes|Veterans Health Administration|Veterans Health Administration,standard_charge|Vitas Healthcare of FL|Vitas|negotiated_dollar,standard_charge|Vitas Healthcare of FL|Vitas|negotiated_percentage,standard_charge|Vitas Healthcare of FL|Vitas|negotiated_algorithm,standard_charge|Vitas Healthcare of FL|Vitas|methodology,median_amount|Vitas Healthcare of FL|Vitas,10th_percentile|Vitas Healthcare of FL|Vitas,90th_percentile|Vitas Healthcare of FL|Vitas,count|Vitas Healthcare of FL|Vitas,additional_payer_notes|Vitas Healthcare of FL|Vitas,standard_charge|WellCare|WellCare|negotiated_dollar,standard_charge|WellCare|WellCare|negotiated_percentage,standard_charge|WellCare|WellCare|negotiated_algorithm,standard_charge|WellCare|WellCare|methodology,median_amount|WellCare|WellCare,10th_percentile|WellCare|WellCare,90th_percentile|WellCare|WellCare,count|WellCare|WellCare,additional_payer_notes|WellCare|WellCare,standard_charge|Workmans Compensation|Workmans Compensation|negotiated_dollar,standard_charge|Workmans Compensation|Workmans Compensation|negotiated_percentage,standard_charge|Workmans Compensation|Workmans Compensation|negotiated_algorithm,standard_charge|Workmans Compensation|Workmans Compensation|methodology,median_amount|Workmans Compensation|Workmans Compensation,10th_percentile|Workmans Compensation|Workmans Compensation,90th_percentile|Workmans Compensation|Workmans Compensation,count|Workmans Compensation|Workmans Compensation,additional_payer_notes|Workmans Compensation|Workmans Compensation
DEX 10percent 500CC 2B0163Q  i,10056,CDM,0258,RC,,,,,,inpatient,facility,,,7.32,7.32,3.29,7.32,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,4.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 10percent 500CC 2B0163Q  i,10056,CDM,0258,RC,,,,,,outpatient,facility,,,7.32,7.32,1.39,1016,,4.76,,,percent of total billed charges,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,,,,2.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,5.49,,,percent of total billed charges,,,,,,5.12,,,percent of total billed charges,,,,,,5.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,,,,1.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,7.32,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.07,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",5.12,,,percent of total billed charges,,,,,,,,,,,,,,,7.32,,,percent of total billed charges,,,,,,5.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.12,,,percent of total billed charges,,,,,,4.39,,,percent of total billed charges,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,6.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.32,,,percent of total billed charges,,,,,,7.32,,,percent of total billed charges,,,,,,3.15,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,7.32,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.32,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.32,,,percent of total billed charges,,,,,,3.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.32,,,fee schedule,,,,,,7.32,,,percent of total billed charges,,,,,,7.32,,,percent of total billed charges,,,,,,7.32,,,percent of total billed charges,,,,,,3.51,,,percent of total billed charges,,,,,,,,,,,,,,,4.32,,,percent of total billed charges,,,,,,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.22,,,percent of total billed charges,,,,,,5.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ENDOTRACH W CUFF MUR 5M,10089,CDM,0272,RC,,,,,,inpatient,facility,,,5.89,5.89,2.65,5.89,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ENDOTRACH W CUFF MUR 5M,10089,CDM,0272,RC,,,,,,outpatient,facility,,,5.89,5.89,1.12,1016,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,1.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.42,,,percent of total billed charges,,,,,,4.12,,,percent of total billed charges,,,,,,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,1.41,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.98,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.89,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.47,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.12,,,percent of total billed charges,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,4.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,3.53,,,percent of total billed charges,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,5.89,,,percent of total billed charges,,,,,,2.53,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.89,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.89,,,percent of total billed charges,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,fee schedule,,,,,,5.89,,,percent of total billed charges,,,,,,5.89,,,percent of total billed charges,,,,,,5.89,,,percent of total billed charges,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.01,,,percent of total billed charges,,,,,,4.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ORAL RAE W CUFF 8.0,10104,CDM,0272,RC,,,,,,inpatient,facility,,,16.65,16.65,7.49,16.65,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,9.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ORAL RAE W CUFF 8.0,10104,CDM,0272,RC,,,,,,outpatient,facility,,,16.65,16.65,3.16,1016,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,4.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,12.49,,,percent of total billed charges,,,,,,11.65,,,percent of total billed charges,,,,,,11.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.24,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.65,,,percent of total billed charges,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,11.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,11.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,9.99,,,percent of total billed charges,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,7.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,,percent of total billed charges,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,fee schedule,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,7.99,,,percent of total billed charges,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.15,,,percent of total billed charges,,,,,,12.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STYLET INTUBATION SHILEY STRL 14FR  i,10105,CDM,0272,RC,,,,,,inpatient,facility,,,4.5,4.5,2.02,4.5,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,,,,2.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,
STYLET INTUBATION SHILEY STRL 14FR  i,10105,CDM,0272,RC,,,,,,outpatient,facility,,,4.5,4.5,0.85,1016,,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.38,,,percent of total billed charges,,,,,,3.15,,,percent of total billed charges,,,,,,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,1.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.04,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.89,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,3.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.15,,,percent of total billed charges,,,,,,2.7,,,percent of total billed charges,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,3.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,4.5,,,percent of total billed charges,,,,,,1.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.5,,,percent of total billed charges,,,,,,2.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.5,,,fee schedule,,,,,,4.5,,,percent of total billed charges,,,,,,4.5,,,percent of total billed charges,,,,,,4.5,,,percent of total billed charges,,,,,,2.16,,,percent of total billed charges,,,,,,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.82,,,percent of total billed charges,,,,,,3.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TRAY CATH TRIPLE LUMEN AGB  8FR 15CM   C UDLMY 801,10138,CDM,0272,RC,,,,,,inpatient,facility,,,491.4,491.4,221.13,491.4,,,,,,,,,,,,,,,,,,,,417.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,343.98,,,percent of total billed charges,,,,,,294.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,417.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,491.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,221.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,417.69,,,percent of total billed charges,,,,,,,,,,,,,,
TRAY CATH TRIPLE LUMEN AGB  8FR 15CM   C UDLMY 801,10138,CDM,0272,RC,,,,,,outpatient,facility,,,491.4,491.4,93.37,1016,,319.41,,,percent of total billed charges,,,,,,,,,,,,,,,417.69,,,percent of total billed charges,,,,,,147.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,230.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,93.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,93.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,368.54,,,percent of total billed charges,,,,,,343.98,,,percent of total billed charges,,,,,,343.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,319.41,,,percent of total billed charges,,,,,,117.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",331.69,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,491.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,206.39,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",343.98,,,percent of total billed charges,,,,,,,,,,,,,,,491.4,,,percent of total billed charges,,,,,,342.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,348.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,343.98,,,percent of total billed charges,,,,,,294.84,,,percent of total billed charges,,,,,,221.13,,,percent of total billed charges,,,,,,,,,,,,,,,417.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.4,,,percent of total billed charges,,,,,,491.4,,,percent of total billed charges,,,,,,211.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,491.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,491.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.55,,,percent of total billed charges,,,,,,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,491.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,491.4,,,percent of total billed charges,,,,,,221.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.4,,,fee schedule,,,,,,491.4,,,percent of total billed charges,,,,,,491.4,,,percent of total billed charges,,,,,,491.4,,,percent of total billed charges,,,,,,235.87,,,percent of total billed charges,,,,,,,,,,,,,,,289.93,,,percent of total billed charges,,,,,,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,491.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,417.69,,,percent of total billed charges,,,,,,368.55,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PUNCH BIOPSY SKIN STRL DISP 3M,10161,CDM,0272,RC,,,,,,inpatient,facility,,,7.78,7.78,3.5,7.78,,,,,,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.45,,,percent of total billed charges,,,,,,4.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,
PUNCH BIOPSY SKIN STRL DISP 3M,10161,CDM,0272,RC,,,,,,outpatient,facility,,,7.78,7.78,1.48,1016,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,2.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,5.83,,,percent of total billed charges,,,,,,5.45,,,percent of total billed charges,,,,,,5.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,1.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",5.25,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7.78,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",5.45,,,percent of total billed charges,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,5.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.45,,,percent of total billed charges,,,,,,4.67,,,percent of total billed charges,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,6.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,7.78,,,percent of total billed charges,,,,,,3.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.78,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.78,,,percent of total billed charges,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.78,,,fee schedule,,,,,,7.78,,,percent of total billed charges,,,,,,7.78,,,percent of total billed charges,,,,,,7.78,,,percent of total billed charges,,,,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,4.59,,,percent of total billed charges,,,,,,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.61,,,percent of total billed charges,,,,,,5.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEADWIRE 3 LEAD SET SNAP UNSHIELD D 3S1563 40IN,10210,CDM,0272,RC,,,,,,inpatient,facility,,,18.69,18.69,8.41,18.69,,,,,,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13.08,,,percent of total billed charges,,,,,,11.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,18.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,,,,,,,,,,,,
LEADWIRE 3 LEAD SET SNAP UNSHIELD D 3S1563 40IN,10210,CDM,0272,RC,,,,,,outpatient,facility,,,18.69,18.69,3.55,1016,,12.15,,,percent of total billed charges,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,,,,5.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,14.02,,,percent of total billed charges,,,,,,13.08,,,percent of total billed charges,,,,,,13.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,12.15,,,percent of total billed charges,,,,,,4.49,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",12.62,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,18.69,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.85,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",13.08,,,percent of total billed charges,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,,,,13.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,13.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13.08,,,percent of total billed charges,,,,,,11.21,,,percent of total billed charges,,,,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,15.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,,,,18.69,,,percent of total billed charges,,,,,,8.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,18.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,18.69,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,18.69,,,percent of total billed charges,,,,,,8.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.69,,,fee schedule,,,,,,18.69,,,percent of total billed charges,,,,,,18.69,,,percent of total billed charges,,,,,,18.69,,,percent of total billed charges,,,,,,8.97,,,percent of total billed charges,,,,,,,,,,,,,,,11.03,,,percent of total billed charges,,,,,,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,18.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,15.89,,,percent of total billed charges,,,,,,14.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH ARTERY RADIAL 20 X 1 3 4  i,10221,CDM,0272,RC,,,,,,inpatient,facility,,,28.84,28.84,12.98,28.84,,,,,,,,,,,,,,,,,,,,24.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.19,,,percent of total billed charges,,,,,,17.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,28.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.51,,,percent of total billed charges,,,,,,,,,,,,,,
CATH ARTERY RADIAL 20 X 1 3 4  i,10221,CDM,0272,RC,,,,,,outpatient,facility,,,28.84,28.84,5.48,1016,,18.75,,,percent of total billed charges,,,,,,,,,,,,,,,24.51,,,percent of total billed charges,,,,,,8.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.63,,,percent of total billed charges,,,,,,20.19,,,percent of total billed charges,,,,,,20.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,18.75,,,percent of total billed charges,,,,,,6.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.47,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,28.84,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.11,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.19,,,percent of total billed charges,,,,,,,,,,,,,,,28.84,,,percent of total billed charges,,,,,,20.12,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.19,,,percent of total billed charges,,,,,,17.3,,,percent of total billed charges,,,,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,24.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.84,,,percent of total billed charges,,,,,,28.84,,,percent of total billed charges,,,,,,12.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,28.84,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,28.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.63,,,percent of total billed charges,,,,,,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.84,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,28.84,,,percent of total billed charges,,,,,,12.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.84,,,fee schedule,,,,,,28.84,,,percent of total billed charges,,,,,,28.84,,,percent of total billed charges,,,,,,28.84,,,percent of total billed charges,,,,,,13.84,,,percent of total billed charges,,,,,,,,,,,,,,,17.02,,,percent of total billed charges,,,,,,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,28.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.51,,,percent of total billed charges,,,,,,21.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL BIOMET HIP RING 52X23,10356,CDM,0278,RC,,,,,,inpatient,facility,,,3168,3168,1425.6,3168,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2692.8,,,percent of total billed charges,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2534.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2376,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1742.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1915.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2249.28,,,percent of total billed charges,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2217.6,,,percent of total billed charges,,,,,,1900.8,,,percent of total billed charges,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2692.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2376,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1425.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2692.8,,,percent of total billed charges,,,,,,2059.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL BIOMET HIP RING 52X23,10356,CDM,0278,RC,,,,,,outpatient,facility,,,3168,3168,129.72,3168,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2692.8,,,percent of total billed charges,,,,,,950.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,601.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,601.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2376,,,percent of total billed charges,,,,,,2217.6,,,percent of total billed charges,,,,,,2217.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2059.2,,,percent of total billed charges,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2217.6,,,percent of total billed charges,,,,,,1742.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3168,,,percent of total billed charges,,,,,,2209.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2249.28,,,percent of total billed charges,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2217.6,,,percent of total billed charges,,,,,,1900.8,,,percent of total billed charges,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2692.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1742.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3168,,,percent of total billed charges,,,,,,3168,,,percent of total billed charges,,,,,,1742.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3168,,,percent of total billed charges,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2376,,,percent of total billed charges,,,,,,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3168,,,percent of total billed charges,,,,,,1425.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2376,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3168,,,fee schedule,,,,,,3168,,,percent of total billed charges,,,,,,3168,,,percent of total billed charges,,,,,,3168,,,percent of total billed charges,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1742.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2692.8,,,percent of total billed charges,,,,,,2376,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SOL NACL 0.9percent 50ML 2B1306  i,10613,CDM,0258,RC,,,,,,inpatient,facility,,,5.47,5.47,2.46,5.47,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,
SOL NACL 0.9percent 50ML 2B1306  i,10613,CDM,0258,RC,,,,,,outpatient,facility,,,5.47,5.47,1.04,1016,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,1.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.1,,,percent of total billed charges,,,,,,3.83,,,percent of total billed charges,,,,,,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,1.31,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,5.47,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.83,,,percent of total billed charges,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,3.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,3.28,,,percent of total billed charges,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,5.47,,,percent of total billed charges,,,,,,2.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.47,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.47,,,percent of total billed charges,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,fee schedule,,,,,,5.47,,,percent of total billed charges,,,,,,5.47,,,percent of total billed charges,,,,,,5.47,,,percent of total billed charges,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.65,,,percent of total billed charges,,,,,,4.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SOL NACL 0.9percent 100ML 2B1307  i,10614,CDM,0258,RC,,,,,,inpatient,facility,,,5.47,5.47,2.46,5.47,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,
SOL NACL 0.9percent 100ML 2B1307  i,10614,CDM,0258,RC,,,,,,outpatient,facility,,,5.47,5.47,1.04,1016,,3.56,,,percent of total billed charges,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,1.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.1,,,percent of total billed charges,,,,,,3.83,,,percent of total billed charges,,,,,,3.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.56,,,percent of total billed charges,,,,,,1.31,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,5.47,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.83,,,percent of total billed charges,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,3.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,3.28,,,percent of total billed charges,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,5.47,,,percent of total billed charges,,,,,,2.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.47,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.47,,,percent of total billed charges,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.47,,,fee schedule,,,,,,5.47,,,percent of total billed charges,,,,,,5.47,,,percent of total billed charges,,,,,,5.47,,,percent of total billed charges,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.23,,,percent of total billed charges,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.65,,,percent of total billed charges,,,,,,4.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SOL NACL INJ 0.9percent 250ML 2B1322Q  i,10620,CDM,0258,RC,,,,,,inpatient,facility,,,4.78,4.78,2.15,4.78,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,,,,2.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,
SOL NACL INJ 0.9percent 250ML 2B1322Q  i,10620,CDM,0258,RC,,,,,,outpatient,facility,,,4.78,4.78,0.91,1016,,3.11,,,percent of total billed charges,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,1.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.59,,,percent of total billed charges,,,,,,3.35,,,percent of total billed charges,,,,,,3.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.11,,,percent of total billed charges,,,,,,1.15,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,4.78,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,3.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.35,,,percent of total billed charges,,,,,,2.87,,,percent of total billed charges,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,4.78,,,percent of total billed charges,,,,,,2.06,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.78,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.78,,,percent of total billed charges,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.78,,,fee schedule,,,,,,4.78,,,percent of total billed charges,,,,,,4.78,,,percent of total billed charges,,,,,,4.78,,,percent of total billed charges,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,2.82,,,percent of total billed charges,,,,,,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.06,,,percent of total billed charges,,,,,,3.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 1.5 X 12.7,10644,CDM,0272,RC,,,,,,inpatient,facility,,,196.24,196.24,88.31,196.24,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.37,,,percent of total billed charges,,,,,,117.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 1.5 X 12.7,10644,CDM,0272,RC,,,,,,outpatient,facility,,,196.24,196.24,37.29,1016,,127.56,,,percent of total billed charges,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,58.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,37.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,147.18,,,percent of total billed charges,,,,,,137.37,,,percent of total billed charges,,,,,,137.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,127.56,,,percent of total billed charges,,,,,,47.1,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",132.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,196.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",137.37,,,percent of total billed charges,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,136.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,139.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.37,,,percent of total billed charges,,,,,,117.74,,,percent of total billed charges,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,84.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,,percent of total billed charges,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,fee schedule,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,94.2,,,percent of total billed charges,,,,,,,,,,,,,,,115.78,,,percent of total billed charges,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.8,,,percent of total billed charges,,,,,,147.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN THRD NS 3 16,10645,CDM,0278,RC,,,,,,inpatient,facility,,,40.24,40.24,18.11,40.24,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,30.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,26.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN THRD NS 3 16,10645,CDM,0278,RC,,,,,,outpatient,facility,,,40.24,40.24,7.65,138.8,,26.16,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30.18,,,percent of total billed charges,,,,,,28.17,,,percent of total billed charges,,,,,,28.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,26.16,,,percent of total billed charges,,,,,,9.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,40.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",28.17,,,percent of total billed charges,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,28.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,17.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,fee schedule,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.2,,,percent of total billed charges,,,,,,30.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE ZIM PLAIN STRL.045  i,10648,CDM,0272,RC,,,,,,inpatient,facility,,,46.86,46.86,21.09,46.86,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.8,,,percent of total billed charges,,,,,,28.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE ZIM PLAIN STRL.045  i,10648,CDM,0272,RC,,,,,,outpatient,facility,,,46.86,46.86,8.9,1016,,30.46,,,percent of total billed charges,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,14.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.14,,,percent of total billed charges,,,,,,32.8,,,percent of total billed charges,,,,,,32.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.46,,,percent of total billed charges,,,,,,11.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",31.63,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.86,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.68,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.8,,,percent of total billed charges,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,32.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.8,,,percent of total billed charges,,,,,,28.12,,,percent of total billed charges,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,20.15,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,,percent of total billed charges,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,fee schedule,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,22.49,,,percent of total billed charges,,,,,,,,,,,,,,,27.65,,,percent of total billed charges,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.83,,,percent of total billed charges,,,,,,35.15,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE ZIM THREAD NSTRL.035,10650,CDM,0272,RC,,,,,,inpatient,facility,,,68.14,68.14,30.66,68.14,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,47.7,,,percent of total billed charges,,,,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE ZIM THREAD NSTRL.035,10650,CDM,0272,RC,,,,,,outpatient,facility,,,68.14,68.14,12.95,1016,,44.29,,,percent of total billed charges,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,20.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,12.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,51.1,,,percent of total billed charges,,,,,,47.7,,,percent of total billed charges,,,,,,47.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.29,,,percent of total billed charges,,,,,,16.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",45.99,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.14,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.62,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",47.7,,,percent of total billed charges,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,47.53,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,47.7,,,percent of total billed charges,,,,,,40.88,,,percent of total billed charges,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,29.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.1,,,percent of total billed charges,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,,percent of total billed charges,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,fee schedule,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,32.71,,,percent of total billed charges,,,,,,,,,,,,,,,40.2,,,percent of total billed charges,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,57.92,,,percent of total billed charges,,,,,,51.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE ZIM THREAD NSTRL.045,10651,CDM,0272,RC,,,,,,inpatient,facility,,,68.14,68.14,30.66,68.14,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,47.7,,,percent of total billed charges,,,,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE ZIM THREAD NSTRL.045,10651,CDM,0272,RC,,,,,,outpatient,facility,,,68.14,68.14,12.95,1016,,44.29,,,percent of total billed charges,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,20.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,12.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,51.1,,,percent of total billed charges,,,,,,47.7,,,percent of total billed charges,,,,,,47.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.29,,,percent of total billed charges,,,,,,16.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",45.99,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.14,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.62,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",47.7,,,percent of total billed charges,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,47.53,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,47.7,,,percent of total billed charges,,,,,,40.88,,,percent of total billed charges,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,29.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.1,,,percent of total billed charges,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,,percent of total billed charges,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,fee schedule,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,32.71,,,percent of total billed charges,,,,,,,,,,,,,,,40.2,,,percent of total billed charges,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,57.92,,,percent of total billed charges,,,,,,51.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE ZIM THREAD NSTRL.062,10652,CDM,0272,RC,,,,,,inpatient,facility,,,68.14,68.14,30.66,68.14,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,47.7,,,percent of total billed charges,,,,,,40.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE ZIM THREAD NSTRL.062,10652,CDM,0272,RC,,,,,,outpatient,facility,,,68.14,68.14,12.95,1016,,44.29,,,percent of total billed charges,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,20.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,12.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,51.1,,,percent of total billed charges,,,,,,47.7,,,percent of total billed charges,,,,,,47.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.29,,,percent of total billed charges,,,,,,16.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",45.99,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.14,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.62,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",47.7,,,percent of total billed charges,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,47.53,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,47.7,,,percent of total billed charges,,,,,,40.88,,,percent of total billed charges,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,57.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,29.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.1,,,percent of total billed charges,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.14,,,percent of total billed charges,,,,,,30.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.14,,,fee schedule,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,68.14,,,percent of total billed charges,,,,,,32.71,,,percent of total billed charges,,,,,,,,,,,,,,,40.2,,,percent of total billed charges,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,57.92,,,percent of total billed charges,,,,,,51.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH SUCTION W CNTRL VLV 18FR  i,107,CDM,0272,RC,,,,,,inpatient,facility,,,3.13,3.13,1.41,3.13,,,,,,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,1.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,
CATH SUCTION W CNTRL VLV 18FR  i,107,CDM,0272,RC,,,,,,outpatient,facility,,,3.13,3.13,0.59,1016,,2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,,,,0.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2.34,,,percent of total billed charges,,,,,,2.19,,,percent of total billed charges,,,,,,2.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,0.75,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.11,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3.13,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.31,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.19,,,percent of total billed charges,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,,,,2.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.19,,,percent of total billed charges,,,,,,1.88,,,percent of total billed charges,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,2.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,,,,3.13,,,percent of total billed charges,,,,,,1.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.13,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.13,,,percent of total billed charges,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.13,,,fee schedule,,,,,,3.13,,,percent of total billed charges,,,,,,3.13,,,percent of total billed charges,,,,,,3.13,,,percent of total billed charges,,,,,,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.66,,,percent of total billed charges,,,,,,2.35,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN PLAIN NS 7 64,10767,CDM,0278,RC,,,,,,inpatient,facility,,,19.2,19.2,8.64,19.2,,,,,,,,,,,,,,,,,,,,16.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.36,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,14.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.61,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",13.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13.44,,,percent of total billed charges,,,,,,11.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,16.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,19.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.32,,,percent of total billed charges,,,,,,12.48,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN PLAIN NS 7 64,10767,CDM,0278,RC,,,,,,outpatient,facility,,,19.2,19.2,3.65,138.8,,12.48,,,percent of total billed charges,,,,,,,,,,,,,,,16.32,,,percent of total billed charges,,,,,,5.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,9.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.56,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,10.56,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10.56,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,10.56,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14.4,,,percent of total billed charges,,,,,,13.44,,,percent of total billed charges,,,,,,13.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,12.48,,,percent of total billed charges,,,,,,4.61,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,19.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,8.06,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",13.44,,,percent of total billed charges,,,,,,,,,,,,,,,19.2,,,percent of total billed charges,,,,,,13.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,13.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13.44,,,percent of total billed charges,,,,,,11.52,,,percent of total billed charges,,,,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,16.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.2,,,percent of total billed charges,,,,,,19.2,,,percent of total billed charges,,,,,,8.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,19.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,19.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.4,,,percent of total billed charges,,,,,,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,19.2,,,percent of total billed charges,,,,,,8.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.2,,,fee schedule,,,,,,19.2,,,percent of total billed charges,,,,,,19.2,,,percent of total billed charges,,,,,,19.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,19.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.32,,,percent of total billed charges,,,,,,14.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN PLAIN NS 9 64,10769,CDM,0278,RC,,,,,,inpatient,facility,,,23.36,23.36,10.51,23.36,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,17.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,16.35,,,percent of total billed charges,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,15.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN PLAIN NS 9 64,10769,CDM,0278,RC,,,,,,outpatient,facility,,,23.36,23.36,4.44,138.8,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,7.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,10.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,17.52,,,percent of total billed charges,,,,,,16.35,,,percent of total billed charges,,,,,,16.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,,,,5.61,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,23.36,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,9.81,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",16.35,,,percent of total billed charges,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,16.29,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,16.35,,,percent of total billed charges,,,,,,14.02,,,percent of total billed charges,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,23.36,,,percent of total billed charges,,,,,,10.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.36,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.36,,,percent of total billed charges,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,fee schedule,,,,,,23.36,,,percent of total billed charges,,,,,,23.36,,,percent of total billed charges,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.86,,,percent of total billed charges,,,,,,17.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN PLAIN NS 5 32,10771,CDM,0278,RC,,,,,,inpatient,facility,,,23.36,23.36,10.51,23.36,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.69,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,17.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,16.35,,,percent of total billed charges,,,,,,14.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,15.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN PLAIN NS 5 32,10771,CDM,0278,RC,,,,,,outpatient,facility,,,23.36,23.36,4.44,138.8,,15.18,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,7.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,10.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,17.52,,,percent of total billed charges,,,,,,16.35,,,percent of total billed charges,,,,,,16.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,15.18,,,percent of total billed charges,,,,,,5.61,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,23.36,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,9.81,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",16.35,,,percent of total billed charges,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,16.29,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,16.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,16.35,,,percent of total billed charges,,,,,,14.02,,,percent of total billed charges,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,19.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,23.36,,,percent of total billed charges,,,,,,10.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.36,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.36,,,percent of total billed charges,,,,,,10.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,fee schedule,,,,,,23.36,,,percent of total billed charges,,,,,,23.36,,,percent of total billed charges,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,23.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.86,,,percent of total billed charges,,,,,,17.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN PLAIN ST 3 16,10772,CDM,0278,RC,,,,,,inpatient,facility,,,40.5,40.5,18.23,40.5,,,,,,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,30.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.48,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",28.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,,,,,24.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,18.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,,,,,26.32,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN PLAIN ST 3 16,10772,CDM,0278,RC,,,,,,outpatient,facility,,,40.5,40.5,7.7,138.8,,26.32,,,percent of total billed charges,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,,,,,12.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,19.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30.38,,,percent of total billed charges,,,,,,28.35,,,percent of total billed charges,,,,,,28.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,26.32,,,percent of total billed charges,,,,,,9.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,40.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,17.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",28.35,,,percent of total billed charges,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,,,,28.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,28.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.35,,,percent of total billed charges,,,,,,24.3,,,percent of total billed charges,,,,,,18.23,,,percent of total billed charges,,,,,,,,,,,,,,,34.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,,,,40.5,,,percent of total billed charges,,,,,,17.41,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,40.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,percent of total billed charges,,,,,,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.5,,,percent of total billed charges,,,,,,18.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,,fee schedule,,,,,,40.5,,,percent of total billed charges,,,,,,40.5,,,percent of total billed charges,,,,,,40.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,40.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.42,,,percent of total billed charges,,,,,,30.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN THRD NS 5 32,10774,CDM,0278,RC,,,,,,inpatient,facility,,,40.24,40.24,18.11,40.24,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,30.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,26.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN THRD NS 5 32,10774,CDM,0278,RC,,,,,,outpatient,facility,,,40.24,40.24,7.65,138.8,,26.16,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30.18,,,percent of total billed charges,,,,,,28.17,,,percent of total billed charges,,,,,,28.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,26.16,,,percent of total billed charges,,,,,,9.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,40.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",28.17,,,percent of total billed charges,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,28.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,17.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,fee schedule,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.2,,,percent of total billed charges,,,,,,30.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN THRD NS 9 64,10782,CDM,0278,RC,,,,,,inpatient,facility,,,24.56,24.56,11.05,24.56,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.65,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,18.42,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.85,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,14.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,24.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,15.96,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN THRD NS 9 64,10782,CDM,0278,RC,,,,,,outpatient,facility,,,24.56,24.56,4.67,138.8,,15.96,,,percent of total billed charges,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,7.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,11.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.51,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.51,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.51,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,13.51,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.42,,,percent of total billed charges,,,,,,17.19,,,percent of total billed charges,,,,,,17.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,15.96,,,percent of total billed charges,,,,,,5.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,24.56,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,10.32,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",17.19,,,percent of total billed charges,,,,,,,,,,,,,,,24.56,,,percent of total billed charges,,,,,,17.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,17.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,17.19,,,percent of total billed charges,,,,,,14.74,,,percent of total billed charges,,,,,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.56,,,percent of total billed charges,,,,,,24.56,,,percent of total billed charges,,,,,,10.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,24.56,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,24.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.42,,,percent of total billed charges,,,,,,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.56,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24.56,,,percent of total billed charges,,,,,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.56,,,fee schedule,,,,,,24.56,,,percent of total billed charges,,,,,,24.56,,,percent of total billed charges,,,,,,24.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,24.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,20.88,,,percent of total billed charges,,,,,,18.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN THRD NS 1 8,10783,CDM,0278,RC,,,,,,inpatient,facility,,,40.24,40.24,18.11,40.24,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,30.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,26.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN THRD NS 1 8,10783,CDM,0278,RC,,,,,,outpatient,facility,,,40.24,40.24,7.65,138.8,,26.16,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30.18,,,percent of total billed charges,,,,,,28.17,,,percent of total billed charges,,,,,,28.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,26.16,,,percent of total billed charges,,,,,,9.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,40.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",28.17,,,percent of total billed charges,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,28.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,17.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,fee schedule,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.2,,,percent of total billed charges,,,,,,30.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN THRD NS 7 64,10784,CDM,0278,RC,,,,,,inpatient,facility,,,40.24,40.24,18.11,40.24,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,30.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,26.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN THRD NS 7 64,10784,CDM,0278,RC,,,,,,outpatient,facility,,,40.24,40.24,7.65,138.8,,26.16,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30.18,,,percent of total billed charges,,,,,,28.17,,,percent of total billed charges,,,,,,28.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,26.16,,,percent of total billed charges,,,,,,9.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,40.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",28.17,,,percent of total billed charges,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,28.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,17.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,fee schedule,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.2,,,percent of total billed charges,,,,,,30.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN THRD NS 5 64,10786,CDM,0278,RC,,,,,,inpatient,facility,,,40.24,40.24,18.11,40.24,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,30.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.33,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,26.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN THRD NS 5 64,10786,CDM,0278,RC,,,,,,outpatient,facility,,,40.24,40.24,7.65,138.8,,26.16,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,12.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30.18,,,percent of total billed charges,,,,,,28.17,,,percent of total billed charges,,,,,,28.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,26.16,,,percent of total billed charges,,,,,,9.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,40.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",28.17,,,percent of total billed charges,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,28.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,28.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.17,,,percent of total billed charges,,,,,,24.14,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,17.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,40.24,,,percent of total billed charges,,,,,,18.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,,fee schedule,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,40.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,40.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.2,,,percent of total billed charges,,,,,,30.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 2.0 X 12.7,10787,CDM,0272,RC,,,,,,inpatient,facility,,,196.24,196.24,88.31,196.24,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.37,,,percent of total billed charges,,,,,,117.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 2.0 X 12.7,10787,CDM,0272,RC,,,,,,outpatient,facility,,,196.24,196.24,37.29,1016,,127.56,,,percent of total billed charges,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,58.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,37.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,147.18,,,percent of total billed charges,,,,,,137.37,,,percent of total billed charges,,,,,,137.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,127.56,,,percent of total billed charges,,,,,,47.1,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",132.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,196.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",137.37,,,percent of total billed charges,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,136.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,139.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.37,,,percent of total billed charges,,,,,,117.74,,,percent of total billed charges,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,84.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,,percent of total billed charges,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,fee schedule,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,94.2,,,percent of total billed charges,,,,,,,,,,,,,,,115.78,,,percent of total billed charges,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.8,,,percent of total billed charges,,,,,,147.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 2.5 X 12.7,10788,CDM,0272,RC,,,,,,inpatient,facility,,,196.24,196.24,88.31,196.24,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.37,,,percent of total billed charges,,,,,,117.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 2.5 X 12.7,10788,CDM,0272,RC,,,,,,outpatient,facility,,,196.24,196.24,37.29,1016,,127.56,,,percent of total billed charges,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,58.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,37.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,147.18,,,percent of total billed charges,,,,,,137.37,,,percent of total billed charges,,,,,,137.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,127.56,,,percent of total billed charges,,,,,,47.1,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",132.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,196.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",137.37,,,percent of total billed charges,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,136.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,139.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.37,,,percent of total billed charges,,,,,,117.74,,,percent of total billed charges,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,84.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,,percent of total billed charges,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,fee schedule,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,94.2,,,percent of total billed charges,,,,,,,,,,,,,,,115.78,,,percent of total billed charges,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.8,,,percent of total billed charges,,,,,,147.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 6PK 2.7 X 12.7,10789,CDM,0272,RC,,,,,,inpatient,facility,,,763.1,763.1,343.4,763.1,,,,,,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,534.17,,,percent of total billed charges,,,,,,457.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,343.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 6PK 2.7 X 12.7,10789,CDM,0272,RC,,,,,,outpatient,facility,,,763.1,763.1,129.72,1016,,496.01,,,percent of total billed charges,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,228.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,358.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,144.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,144.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,572.32,,,percent of total billed charges,,,,,,534.17,,,percent of total billed charges,,,,,,534.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,496.02,,,percent of total billed charges,,,,,,183.14,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",515.09,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,763.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,320.5,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",534.17,,,percent of total billed charges,,,,,,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,532.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,541.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,534.17,,,percent of total billed charges,,,,,,457.86,,,percent of total billed charges,,,,,,343.4,,,percent of total billed charges,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,763.1,,,percent of total billed charges,,,,,,328.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,763.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.33,,,percent of total billed charges,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,763.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,763.1,,,percent of total billed charges,,,,,,343.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,,fee schedule,,,,,,763.1,,,percent of total billed charges,,,,,,763.1,,,percent of total billed charges,,,,,,763.1,,,percent of total billed charges,,,,,,366.29,,,percent of total billed charges,,,,,,,,,,,,,,,450.23,,,percent of total billed charges,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,648.64,,,percent of total billed charges,,,,,,572.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FINGER TRAP ALLEN MESH SML  i,10790,CDM,0270,RC,,,,,,inpatient,facility,,,82.81,82.81,37.26,82.81,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.97,,,percent of total billed charges,,,,,,49.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,
FINGER TRAP ALLEN MESH SML  i,10790,CDM,0270,RC,,,,,,outpatient,facility,,,82.81,82.81,15.73,1016,,53.83,,,percent of total billed charges,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,24.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,38.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,15.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,62.11,,,percent of total billed charges,,,,,,57.97,,,percent of total billed charges,,,,,,57.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,53.83,,,percent of total billed charges,,,,,,19.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",55.9,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,82.81,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.78,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",57.97,,,percent of total billed charges,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,57.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,58.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.97,,,percent of total billed charges,,,,,,49.69,,,percent of total billed charges,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,35.61,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,,percent of total billed charges,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,fee schedule,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,39.75,,,percent of total billed charges,,,,,,,,,,,,,,,48.86,,,percent of total billed charges,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.39,,,percent of total billed charges,,,,,,62.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 6PK 3.2 X 12.7,10791,CDM,0272,RC,,,,,,inpatient,facility,,,763.1,763.1,343.4,763.1,,,,,,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,534.17,,,percent of total billed charges,,,,,,457.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,343.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 6PK 3.2 X 12.7,10791,CDM,0272,RC,,,,,,outpatient,facility,,,763.1,763.1,129.72,1016,,496.01,,,percent of total billed charges,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,228.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,358.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,144.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,144.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,572.32,,,percent of total billed charges,,,,,,534.17,,,percent of total billed charges,,,,,,534.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,496.02,,,percent of total billed charges,,,,,,183.14,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",515.09,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,763.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,320.5,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",534.17,,,percent of total billed charges,,,,,,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,532.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,541.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,534.17,,,percent of total billed charges,,,,,,457.86,,,percent of total billed charges,,,,,,343.4,,,percent of total billed charges,,,,,,,,,,,,,,,648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,763.1,,,percent of total billed charges,,,,,,328.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,763.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.33,,,percent of total billed charges,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,763.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,763.1,,,percent of total billed charges,,,,,,343.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,572.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,763.1,,,fee schedule,,,,,,763.1,,,percent of total billed charges,,,,,,763.1,,,percent of total billed charges,,,,,,763.1,,,percent of total billed charges,,,,,,366.29,,,percent of total billed charges,,,,,,,,,,,,,,,450.23,,,percent of total billed charges,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,763.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,648.64,,,percent of total billed charges,,,,,,572.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 6PK 3.5 X 12.7,10793,CDM,0272,RC,,,,,,inpatient,facility,,,127.19,127.19,57.24,127.19,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.03,,,percent of total billed charges,,,,,,76.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 6PK 3.5 X 12.7,10793,CDM,0272,RC,,,,,,outpatient,facility,,,127.19,127.19,24.17,1016,,82.67,,,percent of total billed charges,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,38.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,24.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,95.39,,,percent of total billed charges,,,,,,89.03,,,percent of total billed charges,,,,,,89.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,,,,30.53,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",85.85,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,127.19,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,53.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",89.03,,,percent of total billed charges,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,88.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.03,,,percent of total billed charges,,,,,,76.31,,,percent of total billed charges,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,54.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,,percent of total billed charges,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,fee schedule,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,61.05,,,percent of total billed charges,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.11,,,percent of total billed charges,,,,,,95.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 6PK 4.0 X 12.7,10794,CDM,0272,RC,,,,,,inpatient,facility,,,127.19,127.19,57.24,127.19,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.03,,,percent of total billed charges,,,,,,76.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 6PK 4.0 X 12.7,10794,CDM,0272,RC,,,,,,outpatient,facility,,,127.19,127.19,24.17,1016,,82.67,,,percent of total billed charges,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,38.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,24.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,95.39,,,percent of total billed charges,,,,,,89.03,,,percent of total billed charges,,,,,,89.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,,,,30.53,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",85.85,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,127.19,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,53.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",89.03,,,percent of total billed charges,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,88.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.03,,,percent of total billed charges,,,,,,76.31,,,percent of total billed charges,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,54.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,,percent of total billed charges,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,fee schedule,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,61.05,,,percent of total billed charges,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.11,,,percent of total billed charges,,,,,,95.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 6PK 4.5 X 12.7,10795,CDM,0272,RC,,,,,,inpatient,facility,,,127.19,127.19,57.24,127.19,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.03,,,percent of total billed charges,,,,,,76.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 6PK 4.5 X 12.7,10795,CDM,0272,RC,,,,,,outpatient,facility,,,127.19,127.19,24.17,1016,,82.67,,,percent of total billed charges,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,38.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,24.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,95.39,,,percent of total billed charges,,,,,,89.03,,,percent of total billed charges,,,,,,89.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,82.67,,,percent of total billed charges,,,,,,30.53,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",85.85,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,127.19,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,53.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",89.03,,,percent of total billed charges,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,88.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.03,,,percent of total billed charges,,,,,,76.31,,,percent of total billed charges,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,108.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,54.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.19,,,percent of total billed charges,,,,,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.19,,,fee schedule,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,127.19,,,percent of total billed charges,,,,,,61.05,,,percent of total billed charges,,,,,,,,,,,,,,,75.04,,,percent of total billed charges,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,127.19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.11,,,percent of total billed charges,,,,,,95.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FINGER TRAP ALLEN MESH MED  i,10798,CDM,0270,RC,,,,,,inpatient,facility,,,82.81,82.81,37.26,82.81,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.97,,,percent of total billed charges,,,,,,49.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,
FINGER TRAP ALLEN MESH MED  i,10798,CDM,0270,RC,,,,,,outpatient,facility,,,82.81,82.81,15.73,1016,,53.83,,,percent of total billed charges,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,24.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,38.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,15.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,62.11,,,percent of total billed charges,,,,,,57.97,,,percent of total billed charges,,,,,,57.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,53.83,,,percent of total billed charges,,,,,,19.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",55.9,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,82.81,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.78,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",57.97,,,percent of total billed charges,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,57.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,58.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.97,,,percent of total billed charges,,,,,,49.69,,,percent of total billed charges,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,35.61,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,,percent of total billed charges,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,fee schedule,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,39.75,,,percent of total billed charges,,,,,,,,,,,,,,,48.86,,,percent of total billed charges,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.39,,,percent of total billed charges,,,,,,62.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT ZIM STRT SHANK 6.4 X 12.7,10799,CDM,0272,RC,,,,,,inpatient,facility,,,196.24,196.24,88.31,196.24,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.37,,,percent of total billed charges,,,,,,117.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT ZIM STRT SHANK 6.4 X 12.7,10799,CDM,0272,RC,,,,,,outpatient,facility,,,196.24,196.24,37.29,1016,,127.56,,,percent of total billed charges,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,58.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,37.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,147.18,,,percent of total billed charges,,,,,,137.37,,,percent of total billed charges,,,,,,137.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,127.56,,,percent of total billed charges,,,,,,47.1,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",132.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,196.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",137.37,,,percent of total billed charges,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,136.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,139.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.37,,,percent of total billed charges,,,,,,117.74,,,percent of total billed charges,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,166.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,84.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,196.24,,,percent of total billed charges,,,,,,88.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.24,,,fee schedule,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,196.24,,,percent of total billed charges,,,,,,94.2,,,percent of total billed charges,,,,,,,,,,,,,,,115.78,,,percent of total billed charges,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,196.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.8,,,percent of total billed charges,,,,,,147.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH SUCTION W CNTRL VLV 10FR  i,108,CDM,0272,RC,,,,,,inpatient,facility,,,2.35,2.35,1.06,2.35,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,
CATH SUCTION W CNTRL VLV 10FR  i,108,CDM,0272,RC,,,,,,outpatient,facility,,,2.35,2.35,0.45,1016,,1.53,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1.77,,,percent of total billed charges,,,,,,1.65,,,percent of total billed charges,,,,,,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1.53,,,percent of total billed charges,,,,,,0.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1.59,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.35,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1.65,,,percent of total billed charges,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,1.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,,1.41,,,percent of total billed charges,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,2.35,,,percent of total billed charges,,,,,,1.01,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.35,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.35,,,percent of total billed charges,,,,,,1.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,fee schedule,,,,,,2.35,,,percent of total billed charges,,,,,,2.35,,,percent of total billed charges,,,,,,2.35,,,percent of total billed charges,,,,,,1.13,,,percent of total billed charges,,,,,,,,,,,,,,,1.39,,,percent of total billed charges,,,,,,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2,,,percent of total billed charges,,,,,,1.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FINGER TRAP ALLEN MESH LRG  i,10800,CDM,0270,RC,,,,,,inpatient,facility,,,82.81,82.81,37.26,82.81,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.97,,,percent of total billed charges,,,,,,49.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,
FINGER TRAP ALLEN MESH LRG  i,10800,CDM,0270,RC,,,,,,outpatient,facility,,,82.81,82.81,15.73,1016,,53.83,,,percent of total billed charges,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,24.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,38.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,15.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,62.11,,,percent of total billed charges,,,,,,57.97,,,percent of total billed charges,,,,,,57.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,53.83,,,percent of total billed charges,,,,,,19.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",55.9,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,82.81,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.78,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",57.97,,,percent of total billed charges,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,57.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,58.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.97,,,percent of total billed charges,,,,,,49.69,,,percent of total billed charges,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,35.61,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,,percent of total billed charges,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,fee schedule,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,39.75,,,percent of total billed charges,,,,,,,,,,,,,,,48.86,,,percent of total billed charges,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.39,,,percent of total billed charges,,,,,,62.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SOL NACL IRR 0.9percent 500ML 2F7123  i,10847,CDM,0258,RC,,,,,,inpatient,facility,,,6.21,6.21,2.79,6.21,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,,,,3.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,
SOL NACL IRR 0.9percent 500ML 2F7123  i,10847,CDM,0258,RC,,,,,,outpatient,facility,,,6.21,6.21,1.18,1016,,4.04,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,1.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.66,,,percent of total billed charges,,,,,,4.35,,,percent of total billed charges,,,,,,4.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4.04,,,percent of total billed charges,,,,,,1.49,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,6.21,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.61,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.35,,,percent of total billed charges,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,4.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,4.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.35,,,percent of total billed charges,,,,,,3.73,,,percent of total billed charges,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,5.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,6.21,,,percent of total billed charges,,,,,,2.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,6.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,,,,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.21,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.21,,,percent of total billed charges,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.21,,,fee schedule,,,,,,6.21,,,percent of total billed charges,,,,,,6.21,,,percent of total billed charges,,,,,,6.21,,,percent of total billed charges,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,,,,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6.21,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.28,,,percent of total billed charges,,,,,,4.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH SUCTION W CNTRL VLV 14FR  i,109,CDM,0272,RC,,,,,,inpatient,facility,,,0.83,0.83,0.37,0.83,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,0.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,
CATH SUCTION W CNTRL VLV 14FR  i,109,CDM,0272,RC,,,,,,outpatient,facility,,,0.83,0.83,0.16,1016,,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,0.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,0.62,,,percent of total billed charges,,,,,,0.58,,,percent of total billed charges,,,,,,0.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.54,,,percent of total billed charges,,,,,,0.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,0.83,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.35,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.58,,,percent of total billed charges,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,0.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.58,,,percent of total billed charges,,,,,,0.5,,,percent of total billed charges,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,0.83,,,percent of total billed charges,,,,,,0.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,0.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.83,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.83,,,percent of total billed charges,,,,,,0.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.83,,,fee schedule,,,,,,0.83,,,percent of total billed charges,,,,,,0.83,,,percent of total billed charges,,,,,,0.83,,,percent of total billed charges,,,,,,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,0.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,0.62,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC VIP PVT NO TELEMETRY,11090025,CDM,0110,RC,,,,,,inpatient,facility,,,3103.1,3103.1,295.98,7000,,3538,,,per diem,,,,,,3103.1,,,fee schedule,,,,,,2637.64,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,,case rate,,,,,,3103.1,,,case rate,,,,,,3103.1,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3103.1,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2172.17,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1551.55,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1551.55,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2017.02,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3103.1,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2172.17,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2203.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2172.17,,,percent of total billed charges,,,,,,1861.86,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2637.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,,percent of total billed charges,,,,,,3103.1,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.86,,,percent of total billed charges,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3103.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2327.32,,,percent of total billed charges,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3103.1,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,,percent of total billed charges,,,,,,1396.39,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,1861.86,,,percent of total billed charges,,,,,,3103.1,,,percent of total billed charges,,,,,,1861.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2637.64,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC VIP PVT  NO TELEMETRY,11090026,CDM,0110,RC,,,,,,inpatient,facility,,,3103.1,3103.1,295.98,7000,,3538,,,per diem,,,,,,3103.1,,,fee schedule,,,,,,2637.64,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,,case rate,,,,,,3103.1,,,case rate,,,,,,3103.1,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3103.1,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2172.17,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1551.55,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1551.55,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2017.02,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3103.1,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2172.17,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2203.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2172.17,,,percent of total billed charges,,,,,,1861.86,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2637.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,,percent of total billed charges,,,,,,3103.1,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.86,,,percent of total billed charges,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3103.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2327.32,,,percent of total billed charges,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3103.1,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,,percent of total billed charges,,,,,,1396.39,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,1861.86,,,percent of total billed charges,,,,,,3103.1,,,percent of total billed charges,,,,,,1861.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2637.64,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC PVT NO TELEMETRY,11090028,CDM,0110,RC,,,,,,inpatient,facility,,,2767.05,2767.05,295.98,7000,,3538,,,per diem,,,,,,2767.05,,,fee schedule,,,,,,2351.99,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,95709.56,95709.56,95709.56,1 through 10,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2767.05,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,2767.05,,,case rate,,,,,,2767.05,,,case rate,,,,,,2767.05,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2767.05,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,1936.93,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1383.53,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1383.53,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1798.58,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,2767.05,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,1936.93,,,percent of total billed charges,,,,,,,,,,,,,,,2767.05,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",1964.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1936.94,,,percent of total billed charges,,,,,,1660.23,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2351.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2767.05,,,percent of total billed charges,,,,,,2767.05,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1660.23,,,percent of total billed charges,,,,,,2767.05,,,fee schedule,,,,,,2767.05,,,fee schedule,,,,,,2767.05,,,fee schedule,,,,,,2767.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,2767.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2075.29,,,percent of total billed charges,,,,,,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2767.05,,,percent of total billed charges,,,,,,,,,,,,,,,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2767.05,,,percent of total billed charges,,,,,,1245.17,,,percent of total billed charges,,,,,,,,,,,,,,,2767.05,,,fee schedule,,,,,,,,,,,,,,,2767.05,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,2767.05,,,fee schedule,,,,,,,,,,,,,,,2767.05,,,fee schedule,,,,,,,,,,,,,,,1660.23,,,percent of total billed charges,,,,,,2767.05,,,percent of total billed charges,,,,,,1660.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2351.99,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC PVT  NO TELEMETRY,11090029,CDM,0110,RC,,,,,,inpatient,facility,,,2767.05,2767.05,295.98,7000,,3538,,,per diem,,,,,,2767.05,,,fee schedule,,,,,,2351.99,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2767.05,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,2767.05,,,case rate,,,,,,2767.05,,,case rate,,,,,,2767.05,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2767.05,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,1936.93,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1383.53,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1383.53,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1798.58,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,2767.05,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,1936.93,,,percent of total billed charges,,,,,,,,,,,,,,,2767.05,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",1964.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1936.94,,,percent of total billed charges,,,,,,1660.23,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2351.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2767.05,,,percent of total billed charges,,,,,,2767.05,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1660.23,,,percent of total billed charges,,,,,,2767.05,,,fee schedule,,,,,,2767.05,,,fee schedule,,,,,,2767.05,,,fee schedule,,,,,,2767.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,2767.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2075.29,,,percent of total billed charges,,,,,,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2767.05,,,percent of total billed charges,,,,,,,,,,,,,,,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2767.05,,,percent of total billed charges,,,,,,1245.17,,,percent of total billed charges,,,,,,,,,,,,,,,2767.05,,,fee schedule,,,,,,,,,,,,,,,2767.05,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,2767.05,,,fee schedule,,,,,,,,,,,,,,,2767.05,,,fee schedule,,,,,,,,,,,,,,,1660.23,,,percent of total billed charges,,,,,,2767.05,,,percent of total billed charges,,,,,,1660.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2767.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2351.99,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC VIP SUITE NO TELEMETRY,11090030,CDM,0110,RC,,,,,,inpatient,facility,,,3016,3016,295.98,7000,,3538,,,per diem,,,,,,3016,,,fee schedule,,,,,,2563.6,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3016,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3016,,,case rate,,,,,,3016,,,case rate,,,,,,3016,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3016,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2111.2,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1508,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1508,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1960.4,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3016,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2111.2,,,percent of total billed charges,,,,,,,,,,,,,,,3016,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2111.2,,,percent of total billed charges,,,,,,1809.6,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2563.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3016,,,percent of total billed charges,,,,,,3016,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1809.6,,,percent of total billed charges,,,,,,3016,,,fee schedule,,,,,,3016,,,fee schedule,,,,,,3016,,,fee schedule,,,,,,3016,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3016,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2262,,,percent of total billed charges,,,,,,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3016,,,percent of total billed charges,,,,,,,,,,,,,,,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3016,,,percent of total billed charges,,,,,,1357.2,,,percent of total billed charges,,,,,,,,,,,,,,,3016,,,fee schedule,,,,,,,,,,,,,,,3016,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3016,,,fee schedule,,,,,,,,,,,,,,,3016,,,fee schedule,,,,,,,,,,,,,,,1809.6,,,percent of total billed charges,,,,,,3016,,,percent of total billed charges,,,,,,1809.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2563.6,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC VIP SUITE  NO TELEMETRY,11090031,CDM,0110,RC,,,,,,inpatient,facility,,,3016,3016,295.98,7000,,3538,,,per diem,,,,,,3016,,,fee schedule,,,,,,2563.6,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3016,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3016,,,case rate,,,,,,3016,,,case rate,,,,,,3016,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3016,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2111.2,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1508,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1508,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1960.4,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3016,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2111.2,,,percent of total billed charges,,,,,,,,,,,,,,,3016,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2111.2,,,percent of total billed charges,,,,,,1809.6,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2563.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3016,,,percent of total billed charges,,,,,,3016,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1809.6,,,percent of total billed charges,,,,,,3016,,,fee schedule,,,,,,3016,,,fee schedule,,,,,,3016,,,fee schedule,,,,,,3016,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3016,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2262,,,percent of total billed charges,,,,,,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3016,,,percent of total billed charges,,,,,,,,,,,,,,,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3016,,,percent of total billed charges,,,,,,1357.2,,,percent of total billed charges,,,,,,,,,,,,,,,3016,,,fee schedule,,,,,,,,,,,,,,,3016,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3016,,,fee schedule,,,,,,,,,,,,,,,3016,,,fee schedule,,,,,,,,,,,,,,,1809.6,,,percent of total billed charges,,,,,,3016,,,percent of total billed charges,,,,,,1809.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3016,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2563.6,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
SYSTEM SUCTION CLOSED BALLARD CATH ADULT 14 X 54,112,CDM,0272,RC,,,,,,inpatient,facility,,,30.1,30.1,13.55,30.1,,,,,,,,,,,,,,,,,,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,21.07,,,percent of total billed charges,,,,,,18.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,
SYSTEM SUCTION CLOSED BALLARD CATH ADULT 14 X 54,112,CDM,0272,RC,,,,,,outpatient,facility,,,30.1,30.1,5.72,1016,,19.57,,,percent of total billed charges,,,,,,,,,,,,,,,25.58,,,percent of total billed charges,,,,,,9.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,22.58,,,percent of total billed charges,,,,,,21.07,,,percent of total billed charges,,,,,,21.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.57,,,percent of total billed charges,,,,,,7.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.32,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,30.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.64,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",21.07,,,percent of total billed charges,,,,,,,,,,,,,,,30.1,,,percent of total billed charges,,,,,,20.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,21.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,21.07,,,percent of total billed charges,,,,,,18.06,,,percent of total billed charges,,,,,,13.55,,,percent of total billed charges,,,,,,,,,,,,,,,25.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.1,,,percent of total billed charges,,,,,,30.1,,,percent of total billed charges,,,,,,12.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,30.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,30.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.58,,,percent of total billed charges,,,,,,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,30.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,30.1,,,percent of total billed charges,,,,,,13.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.1,,,fee schedule,,,,,,30.1,,,percent of total billed charges,,,,,,30.1,,,percent of total billed charges,,,,,,30.1,,,percent of total billed charges,,,,,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,17.76,,,percent of total billed charges,,,,,,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,30.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,25.58,,,percent of total billed charges,,,,,,22.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI MCATEE 7 16,11258,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI MCATEE 7 16,11258,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI MCATEE 5 16,11261,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI MCATEE 5 16,11261,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC LandD S P,11290030,CDM,0122,RC,,,,,,inpatient,facility,,,3380.52,3380.52,295.98,7000,,3538,,,per diem,,,,,,3380.52,,,fee schedule,,,,,,2873.44,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3380.52,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3380.52,,,case rate,,,,,,3380.52,,,case rate,,,,,,3380.52,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3380.52,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2366.36,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1690.26,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1690.26,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2197.34,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3380.52,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2366.36,,,percent of total billed charges,,,,,,,,,,,,,,,3380.52,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2400.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2366.36,,,percent of total billed charges,,,,,,2028.31,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2873.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3380.52,,,percent of total billed charges,,,,,,3380.52,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2028.31,,,percent of total billed charges,,,,,,3380.52,,,fee schedule,,,,,,3380.52,,,fee schedule,,,,,,3380.52,,,fee schedule,,,,,,3380.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3380.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2535.39,,,percent of total billed charges,,,,,,3380.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3380.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3380.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3380.52,,,percent of total billed charges,,,,,,,,,,,,,,,3380.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3380.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3380.52,,,percent of total billed charges,,,,,,1521.23,,,percent of total billed charges,,,,,,,,,,,,,,,3380.52,,,fee schedule,,,,,,,,,,,,,,,3380.52,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3380.52,,,fee schedule,,,,,,,,,,,,,,,3380.52,,,fee schedule,,,,,,,,,,,,,,,2028.31,,,percent of total billed charges,,,,,,3380.52,,,percent of total billed charges,,,,,,2028.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3380.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3380.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2873.44,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
WAFER DURAHESIVE SUR FIT MED W FLANGE 1 3 4  i,11403,CDM,0272,RC,,,,,,inpatient,facility,,,1.15,1.15,0.52,1.15,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,
WAFER DURAHESIVE SUR FIT MED W FLANGE 1 3 4  i,11403,CDM,0272,RC,,,,,,outpatient,facility,,,1.15,1.15,0.22,1016,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,0.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,0.87,,,percent of total billed charges,,,,,,0.81,,,percent of total billed charges,,,,,,0.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,0.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.78,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1.15,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.48,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.8,,,percent of total billed charges,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,0.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,,0.69,,,percent of total billed charges,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,0.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,1.15,,,percent of total billed charges,,,,,,0.49,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.15,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1.15,,,percent of total billed charges,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.15,,,fee schedule,,,,,,1.15,,,percent of total billed charges,,,,,,1.15,,,percent of total billed charges,,,,,,1.15,,,percent of total billed charges,,,,,,0.55,,,percent of total billed charges,,,,,,,,,,,,,,,0.68,,,percent of total billed charges,,,,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.98,,,percent of total billed charges,,,,,,0.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FORCEP BX RADIAL JAW 4 HOT 2.2M 240CM BX 5  i,11510,CDM,0272,RC,,,,,,inpatient,facility,,,181.65,181.65,81.74,181.65,,,,,,,,,,,,,,,,,,,,154.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,127.16,,,percent of total billed charges,,,,,,108.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,181.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,81.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.4,,,percent of total billed charges,,,,,,,,,,,,,,
FORCEP BX RADIAL JAW 4 HOT 2.2M 240CM BX 5  i,11510,CDM,0272,RC,,,,,,outpatient,facility,,,181.65,181.65,34.51,1016,,118.07,,,percent of total billed charges,,,,,,,,,,,,,,,154.4,,,percent of total billed charges,,,,,,54.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,34.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,34.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,136.23,,,percent of total billed charges,,,,,,127.16,,,percent of total billed charges,,,,,,127.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,118.07,,,percent of total billed charges,,,,,,43.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",122.61,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,181.65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,76.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",127.16,,,percent of total billed charges,,,,,,,,,,,,,,,181.65,,,percent of total billed charges,,,,,,126.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,128.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,127.16,,,percent of total billed charges,,,,,,108.99,,,percent of total billed charges,,,,,,81.74,,,percent of total billed charges,,,,,,,,,,,,,,,154.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.65,,,percent of total billed charges,,,,,,181.65,,,percent of total billed charges,,,,,,78.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,181.65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,181.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.24,,,percent of total billed charges,,,,,,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,181.65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,181.65,,,percent of total billed charges,,,,,,81.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.65,,,fee schedule,,,,,,181.65,,,percent of total billed charges,,,,,,181.65,,,percent of total billed charges,,,,,,181.65,,,percent of total billed charges,,,,,,87.19,,,percent of total billed charges,,,,,,,,,,,,,,,107.17,,,percent of total billed charges,,,,,,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,181.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,154.4,,,percent of total billed charges,,,,,,136.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SET SMI HEX FIT,11522,CDM,0278,RC,,,,,,inpatient,facility,,,3.2,3.2,1.44,3.2,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,1.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,2.08,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SET SMI HEX FIT,11522,CDM,0278,RC,,,,,,outpatient,facility,,,3.2,3.2,0.61,138.8,,2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,0.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2.4,,,percent of total billed charges,,,,,,2.24,,,percent of total billed charges,,,,,,2.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,0.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,3.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.34,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.24,,,percent of total billed charges,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,2.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.24,,,percent of total billed charges,,,,,,1.92,,,percent of total billed charges,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,3.2,,,percent of total billed charges,,,,,,1.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.2,,,percent of total billed charges,,,,,,1.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,,fee schedule,,,,,,3.2,,,percent of total billed charges,,,,,,3.2,,,percent of total billed charges,,,,,,3.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.72,,,percent of total billed charges,,,,,,2.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH SWAN GANZ CCOMBO V THERMODILUTION VIP PORT 8F,116,CDM,0272,RC,,,,,,inpatient,facility,,,1137.5,1137.5,511.88,1137.5,,,,,,,,,,,,,,,,,,,,966.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,807.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,796.25,,,percent of total billed charges,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,966.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,511.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,966.88,,,percent of total billed charges,,,,,,,,,,,,,,
CATH SWAN GANZ CCOMBO V THERMODILUTION VIP PORT 8F,116,CDM,0272,RC,,,,,,outpatient,facility,,,1137.5,1137.5,129.72,1137.5,,739.38,,,percent of total billed charges,,,,,,,,,,,,,,,966.88,,,percent of total billed charges,,,,,,341.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,534.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,216.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,216.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,853.12,,,percent of total billed charges,,,,,,796.25,,,percent of total billed charges,,,,,,796.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,739.38,,,percent of total billed charges,,,,,,273,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",767.81,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1137.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,477.75,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",796.25,,,percent of total billed charges,,,,,,,,,,,,,,,1137.5,,,percent of total billed charges,,,,,,793.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,807.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,796.25,,,percent of total billed charges,,,,,,682.5,,,percent of total billed charges,,,,,,511.88,,,percent of total billed charges,,,,,,,,,,,,,,,966.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.5,,,percent of total billed charges,,,,,,1137.5,,,percent of total billed charges,,,,,,489.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1137.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.12,,,percent of total billed charges,,,,,,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1137.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1137.5,,,percent of total billed charges,,,,,,511.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.5,,,fee schedule,,,,,,1137.5,,,percent of total billed charges,,,,,,1137.5,,,percent of total billed charges,,,,,,1137.5,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,671.13,,,percent of total billed charges,,,,,,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1137.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,966.88,,,percent of total billed charges,,,,,,853.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS 2.7 X 24,11678,CDM,0278,RC,,,,,,inpatient,facility,,,92.02,92.02,41.41,92.02,,,,,,,,,,,,,,,,,,,,78.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.62,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,69.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.63,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",65.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,64.41,,,percent of total billed charges,,,,,,55.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,78.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,92.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,41.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.22,,,percent of total billed charges,,,,,,59.81,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS 2.7 X 24,11678,CDM,0278,RC,,,,,,outpatient,facility,,,92.02,92.02,17.48,138.8,,59.81,,,percent of total billed charges,,,,,,,,,,,,,,,78.22,,,percent of total billed charges,,,,,,27.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,17.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,50.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,69.01,,,percent of total billed charges,,,,,,64.41,,,percent of total billed charges,,,,,,64.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,59.81,,,percent of total billed charges,,,,,,22.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,92.02,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,38.65,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",64.41,,,percent of total billed charges,,,,,,,,,,,,,,,92.02,,,percent of total billed charges,,,,,,64.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,65.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,64.41,,,percent of total billed charges,,,,,,55.21,,,percent of total billed charges,,,,,,41.41,,,percent of total billed charges,,,,,,,,,,,,,,,78.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.02,,,percent of total billed charges,,,,,,92.02,,,percent of total billed charges,,,,,,39.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,92.02,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,92.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.02,,,percent of total billed charges,,,,,,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.02,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,92.02,,,percent of total billed charges,,,,,,41.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.02,,,fee schedule,,,,,,92.02,,,percent of total billed charges,,,,,,92.02,,,percent of total billed charges,,,,,,92.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,92.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,78.22,,,percent of total billed charges,,,,,,69.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DELIVERY SYS CO SET INJECTATE ROOM TEMP  i,118,CDM,0272,RC,,,,,,inpatient,facility,,,74.34,74.34,33.45,74.34,,,,,,,,,,,,,,,,,,,,63.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.04,,,percent of total billed charges,,,,,,44.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,74.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,33.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.19,,,percent of total billed charges,,,,,,,,,,,,,,
DELIVERY SYS CO SET INJECTATE ROOM TEMP  i,118,CDM,0272,RC,,,,,,outpatient,facility,,,74.34,74.34,14.12,1016,,48.32,,,percent of total billed charges,,,,,,,,,,,,,,,63.19,,,percent of total billed charges,,,,,,22.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,34.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,55.76,,,percent of total billed charges,,,,,,52.04,,,percent of total billed charges,,,,,,52.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,48.32,,,percent of total billed charges,,,,,,17.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",50.18,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,74.34,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,31.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",52.04,,,percent of total billed charges,,,,,,,,,,,,,,,74.34,,,percent of total billed charges,,,,,,51.85,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,52.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.04,,,percent of total billed charges,,,,,,44.6,,,percent of total billed charges,,,,,,33.45,,,percent of total billed charges,,,,,,,,,,,,,,,63.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.34,,,percent of total billed charges,,,,,,74.34,,,percent of total billed charges,,,,,,31.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,74.34,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,74.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.76,,,percent of total billed charges,,,,,,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.34,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.34,,,percent of total billed charges,,,,,,33.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.34,,,fee schedule,,,,,,74.34,,,percent of total billed charges,,,,,,74.34,,,percent of total billed charges,,,,,,74.34,,,percent of total billed charges,,,,,,35.68,,,percent of total billed charges,,,,,,,,,,,,,,,43.86,,,percent of total billed charges,,,,,,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,74.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,63.19,,,percent of total billed charges,,,,,,55.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SUITE REHAB,11890025,CDM,0118,RC,,,,,,inpatient,facility,,,3103.1,3103.1,295.98,7000,,1843,,,per diem,,,,,,3103.1,,,fee schedule,,,,,,2637.64,,,percent of total billed charges,,,,,,,,,,,,,,,1079,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1446,,Interim Value: REHAB REVS  Procedure Lookup:  Procedure Code Tables:   [[BCBS HMO REHAB REVS]] 100.00% of Table  Multipliers: 100.00% Limited  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N FormulaCPE:  {Days in Visit} * {iv:REHAB REVS} End FormulaCPE,other,,,,0,Interim Value: REHAB REVS  Procedure Lookup:  Procedure Code Tables:   [[BCBS HMO REHAB REVS]] 100.00% of Table  Multipliers: 100.00% Limited  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N FormulaCPE:  {Days in Visit} * {iv:REHAB REVS} End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1501,,Interim Value: REHAB REVS RATE  Procedure Lookup:  Procedure Code Tables:   [[BCBS REHAB REVS]] 100.00% of Table  Multipliers: 100.00% Limited  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N FormulaCPE:  {Days in Visit} * {iv:REHAB REVS RATE} End FormulaCPE,other,,,,0,Interim Value: REHAB REVS RATE  Procedure Lookup:  Procedure Code Tables:   [[BCBS REHAB REVS]] 100.00% of Table  Multipliers: 100.00% Limited  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N FormulaCPE:  {Days in Visit} * {iv:REHAB REVS RATE} End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.,1538,,Interim Value: REHAB REVS  Procedure Lookup:  Procedure Code Tables:   [[BCBS PPO REHAB REVS]] 100.00% of Table  Multipliers: 100.00% Limited  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N FormulaCPE:  {Days in Visit} * {iv:REHAB REVS} End FormulaCPE,other,,,,0,Interim Value: REHAB REVS  Procedure Lookup:  Procedure Code Tables:   [[BCBS PPO REHAB REVS]] 100.00% of Table  Multipliers: 100.00% Limited  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N FormulaCPE:  {Days in Visit} * {iv:REHAB REVS} End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.,1062,,,per diem,,,,,,1464,,Interim Value: REHAB REVS  Procedure Lookup:  Procedure Code Tables:   [[BCBS TRAD REHAB REVS]] 100.00% of Table  Multipliers: 100.00% Limited  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N FormulaCPE:  {Days in Visit} * {iv:REHAB REVS} End FormulaCPE,other,,,,0,Interim Value: REHAB REVS  Procedure Lookup:  Procedure Code Tables:   [[BCBS TRAD REHAB REVS]] 100.00% of Table  Multipliers: 100.00% Limited  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N FormulaCPE:  {Days in Visit} * {iv:REHAB REVS} End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.,1960,,,per diem,,,,,,900,,,per diem,,,,,,2172.17,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1551.55,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1551.55,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2017.02,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3103.1,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1711,,,per diem,,,,,,2172.17,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2203.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2172.17,,,percent of total billed charges,,,,,,1861.86,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2637.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3103.1,,,percent of total billed charges,,,,,,3103.1,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1861.86,,,percent of total billed charges,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3103.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2327.32,,,percent of total billed charges,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3103.1,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3103.1,,,percent of total billed charges,,,,,,1396.39,,,percent of total billed charges,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,3103.1,,,fee schedule,,,,,,,,,,,,,,,1861.86,,,percent of total billed charges,,,,,,3103.1,,,percent of total billed charges,,,,,,1861.86,,,percent of total billed charges,,,,,,3111,,,per diem,,,,,,,,,,,,,,,5318,,,per diem,,,,,,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3103.1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2637.64,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
CATH URET RED RUBBER 8FR  i,119,CDM,0272,RC,,,,,,inpatient,facility,,,2.9,2.9,1.3,2.9,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,
CATH URET RED RUBBER 8FR  i,119,CDM,0272,RC,,,,,,outpatient,facility,,,2.9,2.9,0.55,1016,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2.18,,,percent of total billed charges,,,,,,2.03,,,percent of total billed charges,,,,,,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,0.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,2.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,1.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,,percent of total billed charges,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,fee schedule,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.46,,,percent of total billed charges,,,,,,2.17,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE SYN 1.25X150,11916,CDM,0272,RC,,,,,,inpatient,facility,,,34.01,34.01,15.3,34.01,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,20.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE SYN 1.25X150,11916,CDM,0272,RC,,,,,,outpatient,facility,,,34.01,34.01,6.46,1016,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,10.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,25.51,,,percent of total billed charges,,,,,,23.81,,,percent of total billed charges,,,,,,23.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,8.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",22.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.01,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",23.81,,,percent of total billed charges,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,23.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,20.41,,,percent of total billed charges,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,14.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,,percent of total billed charges,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,fee schedule,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,16.32,,,percent of total billed charges,,,,,,,,,,,,,,,20.07,,,percent of total billed charges,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.91,,,percent of total billed charges,,,,,,25.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE SYN 1.6X150,11917,CDM,0272,RC,,,,,,inpatient,facility,,,34.01,34.01,15.3,34.01,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,20.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE SYN 1.6X150,11917,CDM,0272,RC,,,,,,outpatient,facility,,,34.01,34.01,6.46,1016,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,10.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,25.51,,,percent of total billed charges,,,,,,23.81,,,percent of total billed charges,,,,,,23.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,8.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",22.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.01,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",23.81,,,percent of total billed charges,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,23.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,20.41,,,percent of total billed charges,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,14.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,,percent of total billed charges,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,fee schedule,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,16.32,,,percent of total billed charges,,,,,,,,,,,,,,,20.07,,,percent of total billed charges,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.91,,,percent of total billed charges,,,,,,25.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE SYN 2.0X150,11918,CDM,0272,RC,,,,,,inpatient,facility,,,34.01,34.01,15.3,34.01,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,20.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE SYN 2.0X150,11918,CDM,0272,RC,,,,,,outpatient,facility,,,34.01,34.01,6.46,1016,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,10.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,25.51,,,percent of total billed charges,,,,,,23.81,,,percent of total billed charges,,,,,,23.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,8.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",22.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.01,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",23.81,,,percent of total billed charges,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,23.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,20.41,,,percent of total billed charges,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,28.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,14.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.01,,,percent of total billed charges,,,,,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.01,,,fee schedule,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,34.01,,,percent of total billed charges,,,,,,16.32,,,percent of total billed charges,,,,,,,,,,,,,,,20.07,,,percent of total billed charges,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.91,,,percent of total billed charges,,,,,,25.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PROSTHESIS ROBINSON STAPES 4.5MM  i,11920,CDM,0278,RC,,,,,,inpatient,facility,,,350.14,350.14,157.56,350.14,,,,,,,,,,,,,,,,,,,,297.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,262.61,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",248.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,245.1,,,percent of total billed charges,,,,,,210.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,297.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,350.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,157.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297.62,,,percent of total billed charges,,,,,,227.59,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PROSTHESIS ROBINSON STAPES 4.5MM  i,11920,CDM,0278,RC,,,,,,outpatient,facility,,,350.14,350.14,66.53,350.14,,227.59,,,percent of total billed charges,,,,,,,,,,,,,,,297.62,,,percent of total billed charges,,,,,,105.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,164.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.58,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,192.58,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.58,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,192.58,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,262.6,,,percent of total billed charges,,,,,,245.1,,,percent of total billed charges,,,,,,245.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,227.59,,,percent of total billed charges,,,,,,84.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,350.14,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,147.06,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",245.1,,,percent of total billed charges,,,,,,,,,,,,,,,350.14,,,percent of total billed charges,,,,,,244.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,248.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,245.1,,,percent of total billed charges,,,,,,210.08,,,percent of total billed charges,,,,,,157.56,,,percent of total billed charges,,,,,,,,,,,,,,,297.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.14,,,percent of total billed charges,,,,,,350.14,,,percent of total billed charges,,,,,,150.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,350.14,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,350.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.6,,,percent of total billed charges,,,,,,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,350.14,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,350.14,,,percent of total billed charges,,,,,,157.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.14,,,fee schedule,,,,,,350.14,,,percent of total billed charges,,,,,,350.14,,,percent of total billed charges,,,,,,350.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,350.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,297.62,,,percent of total billed charges,,,,,,262.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PROSTHESIS ROBINSON STAPES 4.0  i,11924,CDM,0278,RC,,,,,,inpatient,facility,,,370.74,370.74,166.83,370.74,,,,,,,,,,,,,,,,,,,,315.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.59,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,278.06,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.11,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",263.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,259.52,,,percent of total billed charges,,,,,,222.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,315.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,370.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.13,,,percent of total billed charges,,,,,,240.98,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PROSTHESIS ROBINSON STAPES 4.0  i,11924,CDM,0278,RC,,,,,,outpatient,facility,,,370.74,370.74,70.44,370.74,,240.98,,,percent of total billed charges,,,,,,,,,,,,,,,315.13,,,percent of total billed charges,,,,,,111.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,174.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,70.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,70.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,203.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,203.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,203.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,278.06,,,percent of total billed charges,,,,,,259.52,,,percent of total billed charges,,,,,,259.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,240.98,,,percent of total billed charges,,,,,,88.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,370.74,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",259.52,,,percent of total billed charges,,,,,,,,,,,,,,,370.74,,,percent of total billed charges,,,,,,258.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,263.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,259.52,,,percent of total billed charges,,,,,,222.44,,,percent of total billed charges,,,,,,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,315.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.74,,,percent of total billed charges,,,,,,370.74,,,percent of total billed charges,,,,,,159.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,370.74,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,370.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.06,,,percent of total billed charges,,,,,,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,370.74,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,370.74,,,percent of total billed charges,,,,,,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.74,,,fee schedule,,,,,,370.74,,,percent of total billed charges,,,,,,370.74,,,percent of total billed charges,,,,,,370.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,370.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,315.13,,,percent of total billed charges,,,,,,278.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH URET RED RUBBER 10FR  i,120,CDM,0272,RC,,,,,,inpatient,facility,,,2.9,2.9,1.3,2.9,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,
CATH URET RED RUBBER 10FR  i,120,CDM,0272,RC,,,,,,outpatient,facility,,,2.9,2.9,0.55,1016,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2.18,,,percent of total billed charges,,,,,,2.03,,,percent of total billed charges,,,,,,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,0.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,2.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,1.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,,percent of total billed charges,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,fee schedule,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.46,,,percent of total billed charges,,,,,,2.17,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEAD MED CAPSUREFIX NOVUS 52CM 4076,12031,CDM,0275,RC,,,,,,inpatient,facility,,,850,850,382.5,850,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,
LEAD MED CAPSUREFIX NOVUS 52CM 4076,12031,CDM,0275,RC,,,,,,outpatient,facility,,,850,850,129.72,850,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,255,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637.5,,,percent of total billed charges,,,,,,595,,,percent of total billed charges,,,,,,595,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,850,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,592.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,850,,,fee schedule,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,722.5,,,percent of total billed charges,,,,,,637.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEAD MED CAPSURE SP NOVUS 58CM 4092,12034,CDM,0275,RC,,,,,,inpatient,facility,,,850,850,382.5,850,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,
LEAD MED CAPSURE SP NOVUS 58CM 4092,12034,CDM,0275,RC,,,,,,outpatient,facility,,,850,850,129.72,850,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,255,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637.5,,,percent of total billed charges,,,,,,595,,,percent of total billed charges,,,,,,595,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,850,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,592.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,850,,,fee schedule,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,722.5,,,percent of total billed charges,,,,,,637.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC S P NO TELEMETRY,12090029,CDM,0120,RC,,,,,,inpatient,facility,,,2602.6,2602.6,295.98,7000,,3538,,,per diem,,,,,,2602.6,,,fee schedule,,,,,,2212.21,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,22705.41,16131.32,39636.26,83,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2602.6,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,2602.6,,,case rate,,,,,,2602.6,,,case rate,,,,,,2602.6,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2602.6,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,1821.82,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1301.3,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1301.3,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1691.69,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,2602.6,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,1821.82,,,percent of total billed charges,,,,,,,,,,,,,,,2602.6,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,6246.24,6246.24,6246.24,1 through 10,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",1847.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1821.82,,,percent of total billed charges,,,,,,1561.56,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2212.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2602.6,,,percent of total billed charges,,,,,,2602.6,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1561.56,,,percent of total billed charges,,,,,,2602.6,,,fee schedule,,,,,,2602.6,,,fee schedule,,,,,,2602.6,,,fee schedule,,,,,,2602.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,2602.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1951.95,,,percent of total billed charges,,,,,,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2602.6,,,percent of total billed charges,,,,,,,,,,,,,,,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2602.6,,,percent of total billed charges,,,,,,1171.17,,,percent of total billed charges,,,,,,,,,,,,,,,2602.6,,,fee schedule,,,,,,,,,,,,,,,2602.6,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,2602.6,,,fee schedule,,,,,,,,,,,,,,,2602.6,,,fee schedule,,,,,,,,,,,,,,,1561.56,,,percent of total billed charges,,,,,,2602.6,,,percent of total billed charges,,,,,,1561.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2212.21,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC KELLER SP NO TELEMETRY,12091619,CDM,0120,RC,,,,,,inpatient,facility,,,2602.6,2602.6,295.98,7000,,3538,,,per diem,,,,,,2602.6,,,fee schedule,,,,,,2212.21,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2602.6,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,2602.6,,,case rate,,,,,,2602.6,,,case rate,,,,,,2602.6,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2602.6,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,1821.82,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1301.3,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1301.3,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1691.69,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,2602.6,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,1821.82,,,percent of total billed charges,,,,,,,,,,,,,,,2602.6,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",1847.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1821.82,,,percent of total billed charges,,,,,,1561.56,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2212.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2602.6,,,percent of total billed charges,,,,,,2602.6,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1561.56,,,percent of total billed charges,,,,,,2602.6,,,fee schedule,,,,,,2602.6,,,fee schedule,,,,,,2602.6,,,fee schedule,,,,,,2602.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,2602.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1951.95,,,percent of total billed charges,,,,,,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2602.6,,,percent of total billed charges,,,,,,,,,,,,,,,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2602.6,,,percent of total billed charges,,,,,,1171.17,,,percent of total billed charges,,,,,,,,,,,,,,,2602.6,,,fee schedule,,,,,,,,,,,,,,,2602.6,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,2602.6,,,fee schedule,,,,,,,,,,,,,,,2602.6,,,fee schedule,,,,,,,,,,,,,,,1561.56,,,percent of total billed charges,,,,,,2602.6,,,percent of total billed charges,,,,,,1561.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2602.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2212.21,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
CATH URET RED RUBBER 12FR  i,121,CDM,0272,RC,,,,,,inpatient,facility,,,2.9,2.9,1.3,2.9,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,
CATH URET RED RUBBER 12FR  i,121,CDM,0272,RC,,,,,,outpatient,facility,,,2.9,2.9,0.55,1016,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2.18,,,percent of total billed charges,,,,,,2.03,,,percent of total billed charges,,,,,,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,0.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,2.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,1.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,,percent of total billed charges,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,fee schedule,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.46,,,percent of total billed charges,,,,,,2.17,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH URET RED RUBBER 14FR  i,122,CDM,0272,RC,,,,,,inpatient,facility,,,2.97,2.97,1.34,2.97,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,
CATH URET RED RUBBER 14FR  i,122,CDM,0272,RC,,,,,,outpatient,facility,,,2.97,2.97,0.56,1016,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,0.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2.22,,,percent of total billed charges,,,,,,2.08,,,percent of total billed charges,,,,,,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,0.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.97,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,2.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,1.78,,,percent of total billed charges,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,2.97,,,percent of total billed charges,,,,,,1.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.97,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.97,,,percent of total billed charges,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,fee schedule,,,,,,2.97,,,percent of total billed charges,,,,,,2.97,,,percent of total billed charges,,,,,,2.97,,,percent of total billed charges,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.52,,,percent of total billed charges,,,,,,2.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ENDOTRACH FLEX TIP REINFORCED CUFFED 7.0,12238,CDM,0272,RC,,,,,,inpatient,facility,,,86.76,86.76,39.04,86.76,,,,,,,,,,,,,,,,,,,,73.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,60.73,,,percent of total billed charges,,,,,,52.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,73.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,86.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.75,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ENDOTRACH FLEX TIP REINFORCED CUFFED 7.0,12238,CDM,0272,RC,,,,,,outpatient,facility,,,86.76,86.76,16.48,1016,,56.39,,,percent of total billed charges,,,,,,,,,,,,,,,73.75,,,percent of total billed charges,,,,,,26.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,40.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,16.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,65.07,,,percent of total billed charges,,,,,,60.73,,,percent of total billed charges,,,,,,60.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,56.39,,,percent of total billed charges,,,,,,20.82,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",58.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,86.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.44,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",60.73,,,percent of total billed charges,,,,,,,,,,,,,,,86.76,,,percent of total billed charges,,,,,,60.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,61.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,60.73,,,percent of total billed charges,,,,,,52.06,,,percent of total billed charges,,,,,,39.04,,,percent of total billed charges,,,,,,,,,,,,,,,73.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,,percent of total billed charges,,,,,,86.76,,,percent of total billed charges,,,,,,37.31,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,86.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.07,,,percent of total billed charges,,,,,,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,86.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,86.76,,,percent of total billed charges,,,,,,39.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,,fee schedule,,,,,,86.76,,,percent of total billed charges,,,,,,86.76,,,percent of total billed charges,,,,,,86.76,,,percent of total billed charges,,,,,,41.64,,,percent of total billed charges,,,,,,,,,,,,,,,51.19,,,percent of total billed charges,,,,,,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,86.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,73.75,,,percent of total billed charges,,,,,,65.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC LandD HIGH RISK,12295003,CDM,0122,RC,,,,,,inpatient,facility,,,4719,4719,295.98,7000,,3538,,,per diem,,,,,,4719,,,fee schedule,,,,,,4011.15,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,21098.68,14811.91,25230.51,35,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4719,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4719,,,case rate,,,,,,4719,,,case rate,,,,,,4719,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4719,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,3303.3,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2359.5,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2359.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3067.35,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4719,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,3303.3,,,percent of total billed charges,,,,,,,,,,,,,,,4719,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3350.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3303.3,,,percent of total billed charges,,,,,,2831.4,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,4011.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4719,,,percent of total billed charges,,,,,,4719,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2831.4,,,percent of total billed charges,,,,,,4719,,,fee schedule,,,,,,4719,,,fee schedule,,,,,,4719,,,fee schedule,,,,,,4719,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4719,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3539.25,,,percent of total billed charges,,,,,,4719,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4719,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4719,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4719,,,percent of total billed charges,,,,,,,,,,,,,,,4719,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4719,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4719,,,percent of total billed charges,,,,,,2123.55,,,percent of total billed charges,,,,,,,,,,,,,,,4719,,,fee schedule,,,,,,,,,,,,,,,4719,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4719,,,fee schedule,,,,,,,,,,,,,,,4719,,,fee schedule,,,,,,,,,,,,,,,2831.4,,,percent of total billed charges,,,,,,4719,,,percent of total billed charges,,,,,,2831.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4719,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4719,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,4011.15,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
CATH URET RED RUBBER 16FR  i,123,CDM,0272,RC,,,,,,inpatient,facility,,,2.97,2.97,1.34,2.97,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,1.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,
CATH URET RED RUBBER 16FR  i,123,CDM,0272,RC,,,,,,outpatient,facility,,,2.97,2.97,0.56,1016,,1.93,,,percent of total billed charges,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,0.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2.22,,,percent of total billed charges,,,,,,2.08,,,percent of total billed charges,,,,,,2.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,,0.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.97,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.08,,,percent of total billed charges,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,2.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.08,,,percent of total billed charges,,,,,,1.78,,,percent of total billed charges,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,2.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,2.97,,,percent of total billed charges,,,,,,1.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.97,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.97,,,percent of total billed charges,,,,,,1.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.97,,,fee schedule,,,,,,2.97,,,percent of total billed charges,,,,,,2.97,,,percent of total billed charges,,,,,,2.97,,,percent of total billed charges,,,,,,1.43,,,percent of total billed charges,,,,,,,,,,,,,,,1.75,,,percent of total billed charges,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.52,,,percent of total billed charges,,,,,,2.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 22 X 30,12339,CDM,0278,RC,,,,,,inpatient,facility,,,1038.08,1038.08,467.14,1038.08,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,882.37,,,percent of total billed charges,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,830.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,778.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,570.94,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,627.52,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",737.04,,,percent of total billed charges,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,726.66,,,percent of total billed charges,,,,,,622.85,,,percent of total billed charges,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,882.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.94,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1038.08,,,percent of total billed charges,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,778.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1038.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,467.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,882.37,,,percent of total billed charges,,,,,,674.75,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 22 X 30,12339,CDM,0278,RC,,,,,,outpatient,facility,,,1038.08,1038.08,129.72,1038.08,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,882.37,,,percent of total billed charges,,,,,,311.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,197.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,197.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,778.56,,,percent of total billed charges,,,,,,726.66,,,percent of total billed charges,,,,,,726.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,674.75,,,percent of total billed charges,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1038.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,726.66,,,percent of total billed charges,,,,,,570.94,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1038.08,,,percent of total billed charges,,,,,,724.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,737.04,,,percent of total billed charges,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,726.66,,,percent of total billed charges,,,,,,622.85,,,percent of total billed charges,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,882.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,570.94,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1038.08,,,percent of total billed charges,,,,,,1038.08,,,percent of total billed charges,,,,,,570.94,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1038.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1038.08,,,percent of total billed charges,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,778.56,,,percent of total billed charges,,,,,,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1038.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1038.08,,,percent of total billed charges,,,,,,467.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1038.08,,,fee schedule,,,,,,1038.08,,,percent of total billed charges,,,,,,1038.08,,,percent of total billed charges,,,,,,1038.08,,,percent of total billed charges,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,570.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1038.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,882.37,,,percent of total billed charges,,,,,,778.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 28 X 30,12340,CDM,0278,RC,,,,,,inpatient,facility,,,1229.38,1229.38,553.22,1229.38,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1044.97,,,percent of total billed charges,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,922.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,676.16,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,743.16,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",872.86,,,percent of total billed charges,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,860.57,,,percent of total billed charges,,,,,,737.63,,,percent of total billed charges,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1044.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.16,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.38,,,percent of total billed charges,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,922.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1229.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,553.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1044.97,,,percent of total billed charges,,,,,,799.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 28 X 30,12340,CDM,0278,RC,,,,,,outpatient,facility,,,1229.38,1229.38,129.72,1229.38,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1044.97,,,percent of total billed charges,,,,,,368.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,233.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,233.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,922.03,,,percent of total billed charges,,,,,,860.57,,,percent of total billed charges,,,,,,860.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,799.1,,,percent of total billed charges,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1229.38,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,860.57,,,percent of total billed charges,,,,,,676.16,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1229.38,,,percent of total billed charges,,,,,,857.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,872.86,,,percent of total billed charges,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,860.57,,,percent of total billed charges,,,,,,737.63,,,percent of total billed charges,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1044.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.16,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1229.38,,,percent of total billed charges,,,,,,1229.38,,,percent of total billed charges,,,,,,676.16,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.38,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.38,,,percent of total billed charges,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,922.04,,,percent of total billed charges,,,,,,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.38,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.38,,,percent of total billed charges,,,,,,553.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,922.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1229.38,,,fee schedule,,,,,,1229.38,,,percent of total billed charges,,,,,,1229.38,,,percent of total billed charges,,,,,,1229.38,,,percent of total billed charges,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,676.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1229.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1044.97,,,percent of total billed charges,,,,,,922.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 32 X 30  c,12342,CDM,0278,RC,,,,,,inpatient,facility,,,1229.92,1229.92,553.46,1229.92,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1045.43,,,percent of total billed charges,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,922.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,676.46,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,743.49,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",873.24,,,percent of total billed charges,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,860.94,,,percent of total billed charges,,,,,,737.95,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1045.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.92,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,922.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1229.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,553.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.43,,,percent of total billed charges,,,,,,799.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 32 X 30  c,12342,CDM,0278,RC,,,,,,outpatient,facility,,,1229.92,1229.92,129.72,1229.92,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1045.43,,,percent of total billed charges,,,,,,368.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,233.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,233.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,922.44,,,percent of total billed charges,,,,,,860.94,,,percent of total billed charges,,,,,,860.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,799.45,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1229.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,860.94,,,percent of total billed charges,,,,,,676.46,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,,percent of total billed charges,,,,,,857.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,873.24,,,percent of total billed charges,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,860.94,,,percent of total billed charges,,,,,,737.95,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1045.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,,percent of total billed charges,,,,,,1229.92,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,922.44,,,percent of total billed charges,,,,,,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.92,,,percent of total billed charges,,,,,,553.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,922.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1229.92,,,fee schedule,,,,,,1229.92,,,percent of total billed charges,,,,,,1229.92,,,percent of total billed charges,,,,,,1229.92,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1045.43,,,percent of total billed charges,,,,,,922.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ENDOTRACH SHILEY N CUFF N DEHP 3.5MM,12375,CDM,0272,RC,,,,,,inpatient,facility,,,4.53,4.53,2.04,4.53,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ENDOTRACH SHILEY N CUFF N DEHP 3.5MM,12375,CDM,0272,RC,,,,,,outpatient,facility,,,4.53,4.53,0.86,1016,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.4,,,percent of total billed charges,,,,,,3.17,,,percent of total billed charges,,,,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,1.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.06,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,3.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,1.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,fee schedule,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.85,,,percent of total billed charges,,,,,,3.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 30,12378,CDM,0278,RC,,,,,,inpatient,facility,,,168,168,75.6,168,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,109.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 30,12378,CDM,0278,RC,,,,,,outpatient,facility,,,168,168,31.92,168,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,50.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126,,,percent of total billed charges,,,,,,117.6,,,percent of total billed charges,,,,,,117.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,40.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.56,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,117.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,72.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,fee schedule,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.8,,,percent of total billed charges,,,,,,126,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 35,12379,CDM,0278,RC,,,,,,inpatient,facility,,,168,168,75.6,168,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,109.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 35,12379,CDM,0278,RC,,,,,,outpatient,facility,,,168,168,31.92,168,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,50.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126,,,percent of total billed charges,,,,,,117.6,,,percent of total billed charges,,,,,,117.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,40.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.56,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,117.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,72.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,fee schedule,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.8,,,percent of total billed charges,,,,,,126,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 45,12381,CDM,0278,RC,,,,,,inpatient,facility,,,169,169,76.05,169,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.16,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,109.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 45,12381,CDM,0278,RC,,,,,,outpatient,facility,,,169,169,32.11,169,,109.85,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,50.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126.75,,,percent of total billed charges,,,,,,118.3,,,percent of total billed charges,,,,,,118.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.85,,,percent of total billed charges,,,,,,40.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,169,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.3,,,percent of total billed charges,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,117.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,72.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,fee schedule,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.65,,,percent of total billed charges,,,,,,126.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 50,12382,CDM,0278,RC,,,,,,inpatient,facility,,,168,168,75.6,168,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,109.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 50,12382,CDM,0278,RC,,,,,,outpatient,facility,,,168,168,31.92,168,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,50.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126,,,percent of total billed charges,,,,,,117.6,,,percent of total billed charges,,,,,,117.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,40.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.56,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,117.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,72.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,fee schedule,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.8,,,percent of total billed charges,,,,,,126,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 55,12383,CDM,0278,RC,,,,,,inpatient,facility,,,169,169,76.05,169,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.16,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,109.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 55,12383,CDM,0278,RC,,,,,,outpatient,facility,,,169,169,32.11,169,,109.85,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,50.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126.75,,,percent of total billed charges,,,,,,118.3,,,percent of total billed charges,,,,,,118.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.85,,,percent of total billed charges,,,,,,40.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,169,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.3,,,percent of total billed charges,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,117.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,72.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,fee schedule,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.65,,,percent of total billed charges,,,,,,126.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 60,12384,CDM,0278,RC,,,,,,inpatient,facility,,,168,168,75.6,168,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,109.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 60,12384,CDM,0278,RC,,,,,,outpatient,facility,,,168,168,31.92,168,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,50.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126,,,percent of total billed charges,,,,,,117.6,,,percent of total billed charges,,,,,,117.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,40.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.56,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,117.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,72.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,fee schedule,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.8,,,percent of total billed charges,,,,,,126,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 65,12385,CDM,0278,RC,,,,,,inpatient,facility,,,168,168,75.6,168,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,109.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 65,12385,CDM,0278,RC,,,,,,outpatient,facility,,,168,168,31.92,168,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,50.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126,,,percent of total billed charges,,,,,,117.6,,,percent of total billed charges,,,,,,117.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,40.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.56,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,117.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,72.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,fee schedule,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.8,,,percent of total billed charges,,,,,,126,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 70,12386,CDM,0278,RC,,,,,,inpatient,facility,,,168,168,75.6,168,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,109.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 70,12386,CDM,0278,RC,,,,,,outpatient,facility,,,168,168,31.92,168,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,50.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126,,,percent of total billed charges,,,,,,117.6,,,percent of total billed charges,,,,,,117.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,40.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.56,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,117.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,72.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,fee schedule,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.8,,,percent of total billed charges,,,,,,126,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 75,12387,CDM,0278,RC,,,,,,inpatient,facility,,,134.4,134.4,60.48,134.4,,,,,,,,,,,,,,,,,,,,114.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,100.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.24,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",95.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.08,,,percent of total billed charges,,,,,,80.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,114.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,134.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.24,,,percent of total billed charges,,,,,,87.36,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 75,12387,CDM,0278,RC,,,,,,outpatient,facility,,,134.4,134.4,25.54,138.8,,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,114.24,,,percent of total billed charges,,,,,,40.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,73.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,73.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,100.8,,,percent of total billed charges,,,,,,94.08,,,percent of total billed charges,,,,,,94.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,87.36,,,percent of total billed charges,,,,,,32.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,134.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.45,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",94.08,,,percent of total billed charges,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,,93.74,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,95.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.08,,,percent of total billed charges,,,,,,80.64,,,percent of total billed charges,,,,,,60.48,,,percent of total billed charges,,,,,,,,,,,,,,,114.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,,134.4,,,percent of total billed charges,,,,,,57.79,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,134.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.8,,,percent of total billed charges,,,,,,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.4,,,percent of total billed charges,,,,,,60.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,fee schedule,,,,,,134.4,,,percent of total billed charges,,,,,,134.4,,,percent of total billed charges,,,,,,134.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,134.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,114.24,,,percent of total billed charges,,,,,,100.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 80,12388,CDM,0278,RC,,,,,,inpatient,facility,,,177.9,177.9,80.06,177.9,,,,,,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,133.43,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.54,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",126.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,,106.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,80.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,115.64,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 80,12388,CDM,0278,RC,,,,,,outpatient,facility,,,177.9,177.9,33.8,177.9,,115.64,,,percent of total billed charges,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,53.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133.42,,,percent of total billed charges,,,,,,124.53,,,percent of total billed charges,,,,,,124.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.64,,,percent of total billed charges,,,,,,42.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.72,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.53,,,percent of total billed charges,,,,,,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,124.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,126.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,,106.74,,,percent of total billed charges,,,,,,80.06,,,percent of total billed charges,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,177.9,,,percent of total billed charges,,,,,,76.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.43,,,percent of total billed charges,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.9,,,percent of total billed charges,,,,,,80.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,,fee schedule,,,,,,177.9,,,percent of total billed charges,,,,,,177.9,,,percent of total billed charges,,,,,,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.22,,,percent of total billed charges,,,,,,133.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 85,12389,CDM,0278,RC,,,,,,inpatient,facility,,,168,168,75.6,168,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,109.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 85,12389,CDM,0278,RC,,,,,,outpatient,facility,,,168,168,31.92,168,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,50.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126,,,percent of total billed charges,,,,,,117.6,,,percent of total billed charges,,,,,,117.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,40.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.56,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,117.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,72.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,fee schedule,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.8,,,percent of total billed charges,,,,,,126,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON DIST LOCK 6.4 X 90,12390,CDM,0278,RC,,,,,,inpatient,facility,,,168,168,75.6,168,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,109.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON DIST LOCK 6.4 X 90,12390,CDM,0278,RC,,,,,,outpatient,facility,,,168,168,31.92,168,,109.2,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,50.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126,,,percent of total billed charges,,,,,,117.6,,,percent of total billed charges,,,,,,117.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.2,,,percent of total billed charges,,,,,,40.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.56,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,117.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.6,,,percent of total billed charges,,,,,,100.8,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,72.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,,fee schedule,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.8,,,percent of total billed charges,,,,,,126,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GUIDE ROD SMI STRT 4.0 X 900,12391,CDM,0272,RC,,,,,,inpatient,facility,,,229.6,229.6,103.32,229.6,,,,,,,,,,,,,,,,,,,,195.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,160.72,,,percent of total billed charges,,,,,,137.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,195.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,229.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.16,,,percent of total billed charges,,,,,,,,,,,,,,
GUIDE ROD SMI STRT 4.0 X 900,12391,CDM,0272,RC,,,,,,outpatient,facility,,,229.6,229.6,43.62,1016,,149.24,,,percent of total billed charges,,,,,,,,,,,,,,,195.16,,,percent of total billed charges,,,,,,68.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,107.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,43.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,172.2,,,percent of total billed charges,,,,,,160.72,,,percent of total billed charges,,,,,,160.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,149.24,,,percent of total billed charges,,,,,,55.1,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154.98,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,229.6,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,96.43,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",160.72,,,percent of total billed charges,,,,,,,,,,,,,,,229.6,,,percent of total billed charges,,,,,,160.15,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,163.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,160.72,,,percent of total billed charges,,,,,,137.76,,,percent of total billed charges,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,195.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.6,,,percent of total billed charges,,,,,,229.6,,,percent of total billed charges,,,,,,98.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,229.6,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,229.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.2,,,percent of total billed charges,,,,,,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,229.6,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,229.6,,,percent of total billed charges,,,,,,103.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.6,,,fee schedule,,,,,,229.6,,,percent of total billed charges,,,,,,229.6,,,percent of total billed charges,,,,,,229.6,,,percent of total billed charges,,,,,,110.21,,,percent of total billed charges,,,,,,,,,,,,,,,135.46,,,percent of total billed charges,,,,,,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,229.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.16,,,percent of total billed charges,,,,,,172.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GUIDE ROD SMI F REAMER 3.2 X 900,12392,CDM,0272,RC,,,,,,inpatient,facility,,,227.6,227.6,102.42,227.6,,,,,,,,,,,,,,,,,,,,193.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,159.32,,,percent of total billed charges,,,,,,136.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,227.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,102.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.46,,,percent of total billed charges,,,,,,,,,,,,,,
GUIDE ROD SMI F REAMER 3.2 X 900,12392,CDM,0272,RC,,,,,,outpatient,facility,,,227.6,227.6,43.24,1016,,147.94,,,percent of total billed charges,,,,,,,,,,,,,,,193.46,,,percent of total billed charges,,,,,,68.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,43.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,170.7,,,percent of total billed charges,,,,,,159.32,,,percent of total billed charges,,,,,,159.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,147.94,,,percent of total billed charges,,,,,,54.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",153.63,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,227.6,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,95.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",159.32,,,percent of total billed charges,,,,,,,,,,,,,,,227.6,,,percent of total billed charges,,,,,,158.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,161.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,159.32,,,percent of total billed charges,,,,,,136.56,,,percent of total billed charges,,,,,,102.42,,,percent of total billed charges,,,,,,,,,,,,,,,193.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.6,,,percent of total billed charges,,,,,,227.6,,,percent of total billed charges,,,,,,97.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,227.6,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,227.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.7,,,percent of total billed charges,,,,,,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,227.6,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,227.6,,,percent of total billed charges,,,,,,102.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.6,,,fee schedule,,,,,,227.6,,,percent of total billed charges,,,,,,227.6,,,percent of total billed charges,,,,,,227.6,,,percent of total billed charges,,,,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,134.28,,,percent of total billed charges,,,,,,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,227.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.46,,,percent of total billed charges,,,,,,170.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GUIDE ROD SMI F REAMER CRVD 3.2 X 900,12393,CDM,0272,RC,,,,,,inpatient,facility,,,237.89,237.89,107.05,237.89,,,,,,,,,,,,,,,,,,,,202.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,166.52,,,percent of total billed charges,,,,,,142.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,202.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,237.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,107.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.21,,,percent of total billed charges,,,,,,,,,,,,,,
GUIDE ROD SMI F REAMER CRVD 3.2 X 900,12393,CDM,0272,RC,,,,,,outpatient,facility,,,237.89,237.89,45.2,1016,,154.63,,,percent of total billed charges,,,,,,,,,,,,,,,202.21,,,percent of total billed charges,,,,,,71.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,111.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,45.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,45.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,178.42,,,percent of total billed charges,,,,,,166.52,,,percent of total billed charges,,,,,,166.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,154.63,,,percent of total billed charges,,,,,,57.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",160.58,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,237.89,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.91,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",166.52,,,percent of total billed charges,,,,,,,,,,,,,,,237.89,,,percent of total billed charges,,,,,,165.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,166.52,,,percent of total billed charges,,,,,,142.73,,,percent of total billed charges,,,,,,107.05,,,percent of total billed charges,,,,,,,,,,,,,,,202.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.89,,,percent of total billed charges,,,,,,237.89,,,percent of total billed charges,,,,,,102.29,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,237.89,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,237.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.42,,,percent of total billed charges,,,,,,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,237.89,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,237.89,,,percent of total billed charges,,,,,,107.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.89,,,fee schedule,,,,,,237.89,,,percent of total billed charges,,,,,,237.89,,,percent of total billed charges,,,,,,237.89,,,percent of total billed charges,,,,,,114.19,,,percent of total billed charges,,,,,,,,,,,,,,,140.36,,,percent of total billed charges,,,,,,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,237.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,202.21,,,percent of total billed charges,,,,,,178.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GUIDE PIN SMI TH 3.2 X 305,12394,CDM,0272,RC,,,,,,inpatient,facility,,,180.04,180.04,81.02,180.04,,,,,,,,,,,,,,,,,,,,153.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,126.03,,,percent of total billed charges,,,,,,108.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,153.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,180.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,81.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.03,,,percent of total billed charges,,,,,,,,,,,,,,
GUIDE PIN SMI TH 3.2 X 305,12394,CDM,0272,RC,,,,,,outpatient,facility,,,180.04,180.04,34.21,1016,,117.03,,,percent of total billed charges,,,,,,,,,,,,,,,153.03,,,percent of total billed charges,,,,,,54.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,84.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,34.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,34.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,135.03,,,percent of total billed charges,,,,,,126.03,,,percent of total billed charges,,,,,,126.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,117.03,,,percent of total billed charges,,,,,,43.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",121.53,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,180.04,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,75.62,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",126.03,,,percent of total billed charges,,,,,,,,,,,,,,,180.04,,,percent of total billed charges,,,,,,125.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,127.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,126.03,,,percent of total billed charges,,,,,,108.02,,,percent of total billed charges,,,,,,81.02,,,percent of total billed charges,,,,,,,,,,,,,,,153.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.04,,,percent of total billed charges,,,,,,180.04,,,percent of total billed charges,,,,,,77.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,180.04,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,180.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.03,,,percent of total billed charges,,,,,,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,180.04,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,180.04,,,percent of total billed charges,,,,,,81.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.04,,,fee schedule,,,,,,180.04,,,percent of total billed charges,,,,,,180.04,,,percent of total billed charges,,,,,,180.04,,,percent of total billed charges,,,,,,86.42,,,percent of total billed charges,,,,,,,,,,,,,,,106.22,,,percent of total billed charges,,,,,,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,180.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,153.03,,,percent of total billed charges,,,,,,135.03,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL TWIST SMI 4.8 X 311,12396,CDM,0272,RC,,,,,,inpatient,facility,,,307.89,307.89,138.55,307.89,,,,,,,,,,,,,,,,,,,,261.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,215.52,,,percent of total billed charges,,,,,,184.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,261.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,307.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,138.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.71,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL TWIST SMI 4.8 X 311,12396,CDM,0272,RC,,,,,,outpatient,facility,,,307.89,307.89,58.5,1016,,200.13,,,percent of total billed charges,,,,,,,,,,,,,,,261.71,,,percent of total billed charges,,,,,,92.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,144.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,58.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,58.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,230.92,,,percent of total billed charges,,,,,,215.52,,,percent of total billed charges,,,,,,215.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,200.13,,,percent of total billed charges,,,,,,73.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",207.83,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,307.89,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,129.31,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",215.52,,,percent of total billed charges,,,,,,,,,,,,,,,307.89,,,percent of total billed charges,,,,,,214.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,218.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,215.52,,,percent of total billed charges,,,,,,184.73,,,percent of total billed charges,,,,,,138.55,,,percent of total billed charges,,,,,,,,,,,,,,,261.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.89,,,percent of total billed charges,,,,,,307.89,,,percent of total billed charges,,,,,,132.39,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,307.89,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,307.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.92,,,percent of total billed charges,,,,,,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,307.89,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,307.89,,,percent of total billed charges,,,,,,138.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.89,,,fee schedule,,,,,,307.89,,,percent of total billed charges,,,,,,307.89,,,percent of total billed charges,,,,,,307.89,,,percent of total billed charges,,,,,,147.79,,,percent of total billed charges,,,,,,,,,,,,,,,181.66,,,percent of total billed charges,,,,,,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,307.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.71,,,percent of total billed charges,,,,,,230.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 12 X 32,12397,CDM,0278,RC,,,,,,inpatient,facility,,,5366.4,5366.4,2414.88,5366.4,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4293.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4024.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2951.52,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3243.99,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3810.14,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3756.48,,,percent of total billed charges,,,,,,3219.84,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5366.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2414.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,3488.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 12 X 32,12397,CDM,0278,RC,,,,,,outpatient,facility,,,5366.4,5366.4,129.72,5366.4,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,1609.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1019.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1019.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4024.8,,,percent of total billed charges,,,,,,3756.48,,,percent of total billed charges,,,,,,3756.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3488.16,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,5366.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3756.48,,,percent of total billed charges,,,,,,2951.52,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,3743.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3810.14,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3756.48,,,percent of total billed charges,,,,,,3219.84,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,,percent of total billed charges,,,,,,2414.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5366.4,,,fee schedule,,,,,,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4561.44,,,percent of total billed charges,,,,,,4024.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 12 X 34,12398,CDM,0278,RC,,,,,,inpatient,facility,,,5366.4,5366.4,2414.88,5366.4,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4293.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4024.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2951.52,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3243.99,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3810.14,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3756.48,,,percent of total billed charges,,,,,,3219.84,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5366.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2414.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,3488.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 12 X 34,12398,CDM,0278,RC,,,,,,outpatient,facility,,,5366.4,5366.4,129.72,5366.4,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,1609.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1019.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1019.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4024.8,,,percent of total billed charges,,,,,,3756.48,,,percent of total billed charges,,,,,,3756.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3488.16,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,5366.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3756.48,,,percent of total billed charges,,,,,,2951.52,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,3743.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3810.14,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3756.48,,,percent of total billed charges,,,,,,3219.84,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,,percent of total billed charges,,,,,,2414.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5366.4,,,fee schedule,,,,,,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4561.44,,,percent of total billed charges,,,,,,4024.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 12 X 36,12399,CDM,0278,RC,,,,,,inpatient,facility,,,5366.4,5366.4,2414.88,5366.4,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4293.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4024.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2951.52,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3243.99,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3810.14,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3756.48,,,percent of total billed charges,,,,,,3219.84,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5366.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2414.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,3488.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 12 X 36,12399,CDM,0278,RC,,,,,,outpatient,facility,,,5366.4,5366.4,129.72,5366.4,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4561.44,,,percent of total billed charges,,,,,,1609.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1019.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1019.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4024.8,,,percent of total billed charges,,,,,,3756.48,,,percent of total billed charges,,,,,,3756.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3488.16,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,5366.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3756.48,,,percent of total billed charges,,,,,,2951.52,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,3743.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3810.14,,,percent of total billed charges,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3756.48,,,percent of total billed charges,,,,,,3219.84,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4561.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5366.4,,,percent of total billed charges,,,,,,2414.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4024.8,,,percent of total billed charges,,,,,,2951.52,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5366.4,,,fee schedule,,,,,,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,5366.4,,,percent of total billed charges,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2951.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5366.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4561.44,,,percent of total billed charges,,,,,,4024.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH URET RED RUBBER 18FR  i,124,CDM,0272,RC,,,,,,inpatient,facility,,,2.9,2.9,1.3,2.9,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,
CATH URET RED RUBBER 18FR  i,124,CDM,0272,RC,,,,,,outpatient,facility,,,2.9,2.9,0.55,1016,,1.89,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,0.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2.18,,,percent of total billed charges,,,,,,2.03,,,percent of total billed charges,,,,,,2.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1.89,,,percent of total billed charges,,,,,,0.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.03,,,percent of total billed charges,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,2.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.03,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,2.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,1.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2.9,,,percent of total billed charges,,,,,,1.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.9,,,fee schedule,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,2.9,,,percent of total billed charges,,,,,,1.39,,,percent of total billed charges,,,,,,,,,,,,,,,1.71,,,percent of total billed charges,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.46,,,percent of total billed charges,,,,,,2.17,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 12 X 38,12400,CDM,0278,RC,,,,,,inpatient,facility,,,2272.4,2272.4,1022.58,2272.4,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1931.54,,,percent of total billed charges,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1704.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1249.82,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1373.67,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1613.4,,,percent of total billed charges,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1590.68,,,percent of total billed charges,,,,,,1363.44,,,percent of total billed charges,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1931.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1249.82,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2272.4,,,percent of total billed charges,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1704.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2272.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1022.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1931.54,,,percent of total billed charges,,,,,,1477.06,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 12 X 38,12400,CDM,0278,RC,,,,,,outpatient,facility,,,2272.4,2272.4,129.72,2272.4,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1931.54,,,percent of total billed charges,,,,,,681.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,431.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,431.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1704.3,,,percent of total billed charges,,,,,,1590.68,,,percent of total billed charges,,,,,,1590.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1477.06,,,percent of total billed charges,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2272.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1590.68,,,percent of total billed charges,,,,,,1249.82,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2272.4,,,percent of total billed charges,,,,,,1585,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1613.4,,,percent of total billed charges,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1590.68,,,percent of total billed charges,,,,,,1363.44,,,percent of total billed charges,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1931.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1249.82,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2272.4,,,percent of total billed charges,,,,,,2272.4,,,percent of total billed charges,,,,,,1249.82,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2272.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2272.4,,,percent of total billed charges,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1704.3,,,percent of total billed charges,,,,,,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2272.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2272.4,,,percent of total billed charges,,,,,,1022.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1704.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2272.4,,,fee schedule,,,,,,2272.4,,,percent of total billed charges,,,,,,2272.4,,,percent of total billed charges,,,,,,2272.4,,,percent of total billed charges,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1249.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2272.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1931.54,,,percent of total billed charges,,,,,,1704.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 12 X 40,12401,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 12 X 40,12401,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 12 X 42,12402,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 12 X 42,12402,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 12 X 44,12403,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 12 X 44,12403,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 13 X 32,12404,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 13 X 32,12404,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 13 X 34,12405,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 13 X 34,12405,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 13 X 36,12406,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 13 X 36,12406,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 13 X 38,12407,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 13 X 38,12407,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 13 X 40,12408,CDM,0278,RC,,,,,,inpatient,facility,,,1806.4,1806.4,812.88,1806.4,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1535.44,,,percent of total billed charges,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1445.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1354.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,993.52,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1091.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1282.54,,,percent of total billed charges,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1264.48,,,percent of total billed charges,,,,,,1083.84,,,percent of total billed charges,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1535.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.52,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1354.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,812.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1535.44,,,percent of total billed charges,,,,,,1174.16,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 13 X 40,12408,CDM,0278,RC,,,,,,outpatient,facility,,,1806.4,1806.4,129.72,1806.4,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1535.44,,,percent of total billed charges,,,,,,541.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,343.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,343.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1354.8,,,percent of total billed charges,,,,,,1264.48,,,percent of total billed charges,,,,,,1264.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1174.16,,,percent of total billed charges,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1806.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1264.48,,,percent of total billed charges,,,,,,993.52,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1806.4,,,percent of total billed charges,,,,,,1259.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1282.54,,,percent of total billed charges,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1264.48,,,percent of total billed charges,,,,,,1083.84,,,percent of total billed charges,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1535.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.52,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1806.4,,,percent of total billed charges,,,,,,1806.4,,,percent of total billed charges,,,,,,993.52,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1806.4,,,percent of total billed charges,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1354.8,,,percent of total billed charges,,,,,,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1806.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1806.4,,,percent of total billed charges,,,,,,812.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1354.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1806.4,,,fee schedule,,,,,,1806.4,,,percent of total billed charges,,,,,,1806.4,,,percent of total billed charges,,,,,,1806.4,,,percent of total billed charges,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,993.52,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1806.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1535.44,,,percent of total billed charges,,,,,,1354.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 13 X 42,12409,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 13 X 42,12409,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 13 X 44,12410,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 13 X 44,12410,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 14 X 36,12411,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 14 X 36,12411,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 14 X 38,12412,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 14 X 38,12412,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 14 X 40,12413,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 14 X 40,12413,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 14 X 42,12414,CDM,0278,RC,,,,,,inpatient,facility,,,2392,2392,1076.4,2392,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2033.2,,,percent of total billed charges,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1913.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1794,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1315.6,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1445.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1698.32,,,percent of total billed charges,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1674.4,,,percent of total billed charges,,,,,,1435.2,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2033.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2392,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1794,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2392,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1076.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2033.2,,,percent of total billed charges,,,,,,1554.8,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 14 X 42,12414,CDM,0278,RC,,,,,,outpatient,facility,,,2392,2392,129.72,2392,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2033.2,,,percent of total billed charges,,,,,,717.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,454.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,454.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1794,,,percent of total billed charges,,,,,,1674.4,,,percent of total billed charges,,,,,,1674.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1554.8,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2392,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1674.4,,,percent of total billed charges,,,,,,1315.6,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,,percent of total billed charges,,,,,,1668.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1698.32,,,percent of total billed charges,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1674.4,,,percent of total billed charges,,,,,,1435.2,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2033.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,,percent of total billed charges,,,,,,2392,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2392,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1794,,,percent of total billed charges,,,,,,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2392,,,percent of total billed charges,,,,,,1076.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1794,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2392,,,fee schedule,,,,,,2392,,,percent of total billed charges,,,,,,2392,,,percent of total billed charges,,,,,,2392,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2033.2,,,percent of total billed charges,,,,,,1794,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 14 X 44,12415,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 14 X 44,12415,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 32,12416,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 32,12416,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 34,12417,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 34,12417,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 36,12418,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 36,12418,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 38,12419,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 38,12419,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 40,12420,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 40,12420,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 42,12421,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 42,12421,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 44,12422,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 44,12422,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 46,12423,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 46,12423,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 48,12424,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 48,12424,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON LT 15 X 50,12425,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON LT 15 X 50,12425,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 12 X 32,12426,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 12 X 32,12426,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 12 X 34,12427,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 12 X 34,12427,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 12 X 36,12428,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 12 X 36,12428,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 12 X 38,12429,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 12 X 38,12429,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 12 X 40,12430,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 12 X 40,12430,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 12 X 42,12431,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 12 X 42,12431,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 12 X 44,12432,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 12 X 44,12432,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 13 X 32,12433,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 13 X 32,12433,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 13 X 34,12434,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 13 X 34,12434,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 13 X 36,12435,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 13 X 36,12435,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 13 X 38,12436,CDM,0278,RC,,,,,,inpatient,facility,,,2392,2392,1076.4,2392,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2033.2,,,percent of total billed charges,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1913.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1794,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1315.6,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1445.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1698.32,,,percent of total billed charges,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1674.4,,,percent of total billed charges,,,,,,1435.2,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2033.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2392,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1794,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2392,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1076.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2033.2,,,percent of total billed charges,,,,,,1554.8,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 13 X 38,12436,CDM,0278,RC,,,,,,outpatient,facility,,,2392,2392,129.72,2392,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2033.2,,,percent of total billed charges,,,,,,717.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,454.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,454.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1794,,,percent of total billed charges,,,,,,1674.4,,,percent of total billed charges,,,,,,1674.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1554.8,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2392,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1674.4,,,percent of total billed charges,,,,,,1315.6,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,,percent of total billed charges,,,,,,1668.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1698.32,,,percent of total billed charges,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1674.4,,,percent of total billed charges,,,,,,1435.2,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2033.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,,percent of total billed charges,,,,,,2392,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2392,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1794,,,percent of total billed charges,,,,,,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2392,,,percent of total billed charges,,,,,,1076.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1794,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2392,,,fee schedule,,,,,,2392,,,percent of total billed charges,,,,,,2392,,,percent of total billed charges,,,,,,2392,,,percent of total billed charges,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1315.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2392,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2033.2,,,percent of total billed charges,,,,,,1794,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 13 X 40,12437,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 13 X 40,12437,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 13 X 42,12438,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 13 X 42,12438,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 13 X 44,12439,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 13 X 44,12439,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INSERT CLAMP STEALTH SOFT TRACTION DISP 90MM  i,1244,CDM,0272,RC,,,,,,inpatient,facility,,,91,91,40.95,91,,,,,,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.7,,,percent of total billed charges,,,,,,54.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,
INSERT CLAMP STEALTH SOFT TRACTION DISP 90MM  i,1244,CDM,0272,RC,,,,,,outpatient,facility,,,91,91,17.29,1016,,59.15,,,percent of total billed charges,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,27.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,42.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,17.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,68.25,,,percent of total billed charges,,,,,,63.7,,,percent of total billed charges,,,,,,63.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,59.15,,,percent of total billed charges,,,,,,21.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.43,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,91,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,38.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",63.7,,,percent of total billed charges,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,63.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.7,,,percent of total billed charges,,,,,,54.6,,,percent of total billed charges,,,,,,40.95,,,percent of total billed charges,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,91,,,percent of total billed charges,,,,,,39.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,91,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,91,,,percent of total billed charges,,,,,,40.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,,fee schedule,,,,,,91,,,percent of total billed charges,,,,,,91,,,percent of total billed charges,,,,,,91,,,percent of total billed charges,,,,,,43.68,,,percent of total billed charges,,,,,,,,,,,,,,,53.69,,,percent of total billed charges,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,77.35,,,percent of total billed charges,,,,,,68.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 14 X 36,12440,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 14 X 36,12440,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 14 X 38,12441,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 14 X 38,12441,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 14 X 40,12442,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 14 X 40,12442,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 14 X 42,12443,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 14 X 42,12443,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 14 X 44,12444,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 14 X 44,12444,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 32,12445,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 32,12445,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 34,12446,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 34,12446,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 36,12447,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 36,12447,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 38,12448,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 38,12448,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 40,12449,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 40,12449,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 42,12450,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 42,12450,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 44,12451,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 44,12451,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 46,12452,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 46,12452,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 48,12453,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 48,12453,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON RT 15 X 50,12454,CDM,0278,RC,,,,,,inpatient,facility,,,2258,2258,1016.1,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1806.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1693.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1364.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,1467.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON RT 15 X 50,12454,CDM,0278,RC,,,,,,outpatient,facility,,,2258,2258,129.72,2258,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.3,,,percent of total billed charges,,,,,,677.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,429.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1693.5,,,percent of total billed charges,,,,,,1580.6,,,percent of total billed charges,,,,,,1580.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1467.7,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1241.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1574.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1603.18,,,percent of total billed charges,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1580.6,,,percent of total billed charges,,,,,,1354.8,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2258,,,percent of total billed charges,,,,,,1016.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2258,,,fee schedule,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,2258,,,percent of total billed charges,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1241.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.3,,,percent of total billed charges,,,,,,1693.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 65,12455,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 65,12455,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 70,12456,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 70,12456,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 75,12457,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 75,12457,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 80,12458,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 80,12458,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 85,12459,CDM,0278,RC,,,,,,inpatient,facility,,,211.2,211.2,95.04,211.2,,,,,,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.96,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,158.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.67,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",149.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,147.84,,,percent of total billed charges,,,,,,126.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,137.28,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 85,12459,CDM,0278,RC,,,,,,outpatient,facility,,,211.2,211.2,40.13,211.2,,137.28,,,percent of total billed charges,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,63.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,99.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,40.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,158.4,,,percent of total billed charges,,,,,,147.84,,,percent of total billed charges,,,,,,147.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,50.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,211.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,88.7,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",147.84,,,percent of total billed charges,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,147.31,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,149.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,147.84,,,percent of total billed charges,,,,,,126.72,,,percent of total billed charges,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,211.2,,,percent of total billed charges,,,,,,90.82,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,211.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,211.2,,,percent of total billed charges,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,fee schedule,,,,,,211.2,,,percent of total billed charges,,,,,,211.2,,,percent of total billed charges,,,,,,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,179.52,,,percent of total billed charges,,,,,,158.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 90,12460,CDM,0278,RC,,,,,,inpatient,facility,,,286,286,128.7,286,,,,,,,,,,,,,,,,,,,,243.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,228.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,214.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.89,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",203.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,200.2,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,243.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,286,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,128.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.1,,,percent of total billed charges,,,,,,185.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 90,12460,CDM,0278,RC,,,,,,outpatient,facility,,,286,286,54.34,286,,185.9,,,percent of total billed charges,,,,,,,,,,,,,,,243.1,,,percent of total billed charges,,,,,,85.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,157.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,157.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,157.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,214.5,,,percent of total billed charges,,,,,,200.2,,,percent of total billed charges,,,,,,200.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,185.9,,,percent of total billed charges,,,,,,68.64,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,286,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,120.12,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",200.2,,,percent of total billed charges,,,,,,,,,,,,,,,286,,,percent of total billed charges,,,,,,199.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,203.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,200.2,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,,128.7,,,percent of total billed charges,,,,,,,,,,,,,,,243.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286,,,percent of total billed charges,,,,,,286,,,percent of total billed charges,,,,,,122.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,286,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,286,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.5,,,percent of total billed charges,,,,,,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,286,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,286,,,percent of total billed charges,,,,,,128.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286,,,fee schedule,,,,,,286,,,percent of total billed charges,,,,,,286,,,percent of total billed charges,,,,,,286,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,286,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,243.1,,,percent of total billed charges,,,,,,214.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 95,12461,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 95,12461,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 100,12462,CDM,0278,RC,,,,,,inpatient,facility,,,258,258,116.1,258,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,193.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,167.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 100,12462,CDM,0278,RC,,,,,,outpatient,facility,,,258,258,49.02,258,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,77.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,121.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,,percent of total billed charges,,,,,,180.6,,,percent of total billed charges,,,,,,180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,61.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",180.6,,,percent of total billed charges,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,179.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,110.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,fee schedule,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.3,,,percent of total billed charges,,,,,,193.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 105,12463,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 105,12463,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 110,12464,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 110,12464,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 115,12465,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 115,12465,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 120,12466,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 120,12466,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 6.4 X 125,12467,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 6.4 X 125,12467,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 65,12468,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 65,12468,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 70,12469,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 70,12469,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 75,12470,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 75,12470,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 80,12471,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 80,12471,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 85,12472,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 85,12472,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 90,12473,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 90,12473,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 95,12474,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 95,12474,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 100,12475,CDM,0278,RC,,,,,,inpatient,facility,,,211.2,211.2,95.04,211.2,,,,,,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.96,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,158.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.67,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",149.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,147.84,,,percent of total billed charges,,,,,,126.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,137.28,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 100,12475,CDM,0278,RC,,,,,,outpatient,facility,,,211.2,211.2,40.13,211.2,,137.28,,,percent of total billed charges,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,63.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,99.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,40.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,158.4,,,percent of total billed charges,,,,,,147.84,,,percent of total billed charges,,,,,,147.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,50.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,211.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,88.7,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",147.84,,,percent of total billed charges,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,147.31,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,149.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,147.84,,,percent of total billed charges,,,,,,126.72,,,percent of total billed charges,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,179.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,211.2,,,percent of total billed charges,,,,,,90.82,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,211.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,211.2,,,percent of total billed charges,,,,,,95.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,fee schedule,,,,,,211.2,,,percent of total billed charges,,,,,,211.2,,,percent of total billed charges,,,,,,211.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,211.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,179.52,,,percent of total billed charges,,,,,,158.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 115,12478,CDM,0278,RC,,,,,,inpatient,facility,,,284,284,127.8,284,,,,,,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,213,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.68,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",201.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,198.8,,,percent of total billed charges,,,,,,170.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,284,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,127.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,184.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 115,12478,CDM,0278,RC,,,,,,outpatient,facility,,,284,284,53.96,284,,184.6,,,percent of total billed charges,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,85.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,133.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,53.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,53.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,156.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,213,,,percent of total billed charges,,,,,,198.8,,,percent of total billed charges,,,,,,198.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,184.6,,,percent of total billed charges,,,,,,68.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,284,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",198.8,,,percent of total billed charges,,,,,,,,,,,,,,,284,,,percent of total billed charges,,,,,,198.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,201.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,198.8,,,percent of total billed charges,,,,,,170.4,,,percent of total billed charges,,,,,,127.8,,,percent of total billed charges,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,,percent of total billed charges,,,,,,284,,,percent of total billed charges,,,,,,122.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,284,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213,,,percent of total billed charges,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,284,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,284,,,percent of total billed charges,,,,,,127.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,,fee schedule,,,,,,284,,,percent of total billed charges,,,,,,284,,,percent of total billed charges,,,,,,284,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.4,,,percent of total billed charges,,,,,,213,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 120,12479,CDM,0278,RC,,,,,,inpatient,facility,,,284,284,127.8,284,,,,,,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,213,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.68,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",201.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,198.8,,,percent of total billed charges,,,,,,170.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,284,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,127.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,184.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 120,12479,CDM,0278,RC,,,,,,outpatient,facility,,,284,284,53.96,284,,184.6,,,percent of total billed charges,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,85.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,133.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,53.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,53.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,156.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,213,,,percent of total billed charges,,,,,,198.8,,,percent of total billed charges,,,,,,198.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,184.6,,,percent of total billed charges,,,,,,68.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,284,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,119.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",198.8,,,percent of total billed charges,,,,,,,,,,,,,,,284,,,percent of total billed charges,,,,,,198.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,201.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,198.8,,,percent of total billed charges,,,,,,170.4,,,percent of total billed charges,,,,,,127.8,,,percent of total billed charges,,,,,,,,,,,,,,,241.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,,percent of total billed charges,,,,,,284,,,percent of total billed charges,,,,,,122.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,284,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213,,,percent of total billed charges,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,284,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,284,,,percent of total billed charges,,,,,,127.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,,fee schedule,,,,,,284,,,percent of total billed charges,,,,,,284,,,percent of total billed charges,,,,,,284,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,284,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.4,,,percent of total billed charges,,,,,,213,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T RECON PROX LOCK 8.0 X 125,12480,CDM,0278,RC,,,,,,inpatient,facility,,,264,264,118.8,264,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,171.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T RECON PROX LOCK 8.0 X 125,12480,CDM,0278,RC,,,,,,outpatient,facility,,,264,264,50.16,264,,171.6,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,79.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.2,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,,184.8,,,percent of total billed charges,,,,,,184.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,171.6,,,percent of total billed charges,,,,,,63.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,264,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",184.8,,,percent of total billed charges,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,184.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,187.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.8,,,percent of total billed charges,,,,,,158.4,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,224.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,113.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,264,,,percent of total billed charges,,,,,,118.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,,fee schedule,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,264,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,264,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.4,,,percent of total billed charges,,,,,,198,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 42MM NC,12482,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 42MM NC,12482,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 43MM NC,12483,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 43MM NC,12483,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 44MM NC,12484,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 44MM NC,12484,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 45MM NC,12485,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 45MM NC,12485,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 46MM NC,12486,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 46MM NC,12486,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 47MM NC,12487,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 47MM NC,12487,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 48MM NC,12488,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 48MM NC,12488,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 49MM NC,12489,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 49MM NC,12489,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 50MM NC,12490,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 50MM NC,12490,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 51MM NC,12491,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 51MM NC,12491,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 52MM NC,12492,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 52MM NC,12492,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 53MM NC,12493,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 53MM NC,12493,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 54MM NC,12494,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 54MM NC,12494,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 55MM NC,12495,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 55MM NC,12495,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP BIO HIP RINGLOC ACET BIPOLAR 58MM NC,12496,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP BIO HIP RINGLOC ACET BIPOLAR 58MM NC,12496,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD BIO HIP COCR MOD 28   6 NC,12502,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD BIO HIP COCR MOD 28   6 NC,12502,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD BIO HIP COCR MOD 28   3 NC,12503,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD BIO HIP COCR MOD 28   3 NC,12503,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD BIO HIP COCR MOD 28   0 NC,12504,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD BIO HIP COCR MOD 28   0 NC,12504,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD BIO HIP COCR MOD 28   3 NC,12505,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD BIO HIP COCR MOD 28   3 NC,12505,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD BIO HIP COCR MOD 28   6 NC,12506,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD BIO HIP COCR MOD 28   6 NC,12506,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD BIO HIP COCR MOD 28   12 NC,12508,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD BIO HIP COCR MOD 28   12 NC,12508,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 28 X 10 X 50,12552,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 28 X 10 X 50,12552,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 28 X 10 X 66,12560,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 28 X 10 X 66,12560,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 1200 50MM,12600,CDM,0278,RC,,,,,,inpatient,facility,,,1970,1970,886.5,1970,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1674.5,,,percent of total billed charges,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1576,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1477.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1083.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1190.86,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1398.7,,,percent of total billed charges,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1379,,,percent of total billed charges,,,,,,1182,,,percent of total billed charges,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1674.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1083.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970,,,percent of total billed charges,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1477.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1970,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,886.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1674.5,,,percent of total billed charges,,,,,,1280.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 1200 50MM,12600,CDM,0278,RC,,,,,,outpatient,facility,,,1970,1970,129.72,1970,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1674.5,,,percent of total billed charges,,,,,,591,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,374.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,374.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1477.5,,,percent of total billed charges,,,,,,1379,,,percent of total billed charges,,,,,,1379,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1280.5,,,percent of total billed charges,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1970,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1379,,,percent of total billed charges,,,,,,1083.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1970,,,percent of total billed charges,,,,,,1374.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1398.7,,,percent of total billed charges,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1379,,,percent of total billed charges,,,,,,1182,,,percent of total billed charges,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1674.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1083.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1970,,,percent of total billed charges,,,,,,1970,,,percent of total billed charges,,,,,,1083.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1970,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1970,,,percent of total billed charges,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1477.5,,,percent of total billed charges,,,,,,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1970,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1970,,,percent of total billed charges,,,,,,886.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1970,,,fee schedule,,,,,,1970,,,percent of total billed charges,,,,,,1970,,,percent of total billed charges,,,,,,1970,,,percent of total billed charges,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1083.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1970,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1674.5,,,percent of total billed charges,,,,,,1477.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 1200 52MM,12601,CDM,0278,RC,,,,,,inpatient,facility,,,2030,2030,913.5,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1624,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1522.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1227.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2030,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,1319.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 1200 52MM,12601,CDM,0278,RC,,,,,,outpatient,facility,,,2030,2030,129.72,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,609,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1522.5,,,percent of total billed charges,,,,,,1421,,,percent of total billed charges,,,,,,1421,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1319.5,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2030,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1415.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,,percent of total billed charges,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2030,,,fee schedule,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1725.5,,,percent of total billed charges,,,,,,1522.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 1200 54MM,12602,CDM,0278,RC,,,,,,inpatient,facility,,,2030,2030,913.5,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1624,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1522.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1227.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2030,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,1319.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 1200 54MM,12602,CDM,0278,RC,,,,,,outpatient,facility,,,2030,2030,129.72,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,609,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1522.5,,,percent of total billed charges,,,,,,1421,,,percent of total billed charges,,,,,,1421,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1319.5,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2030,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1415.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,,percent of total billed charges,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2030,,,fee schedule,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1725.5,,,percent of total billed charges,,,,,,1522.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 1200 58MM,12604,CDM,0278,RC,,,,,,inpatient,facility,,,2030,2030,913.5,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1624,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1522.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1227.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2030,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,1319.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 1200 58MM,12604,CDM,0278,RC,,,,,,outpatient,facility,,,2030,2030,129.72,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,609,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1522.5,,,percent of total billed charges,,,,,,1421,,,percent of total billed charges,,,,,,1421,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1319.5,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2030,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1415.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,,percent of total billed charges,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2030,,,fee schedule,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1725.5,,,percent of total billed charges,,,,,,1522.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 1200 60MM,12605,CDM,0278,RC,,,,,,inpatient,facility,,,2030,2030,913.5,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1624,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1522.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1227.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2030,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,1319.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 1200 60MM,12605,CDM,0278,RC,,,,,,outpatient,facility,,,2030,2030,129.72,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,609,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1522.5,,,percent of total billed charges,,,,,,1421,,,percent of total billed charges,,,,,,1421,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1319.5,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2030,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1415.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,,percent of total billed charges,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2030,,,fee schedule,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1725.5,,,percent of total billed charges,,,,,,1522.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 1200 62MM,12606,CDM,0278,RC,,,,,,inpatient,facility,,,2030,2030,913.5,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1624,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1522.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1227.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2030,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,1319.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 1200 62MM,12606,CDM,0278,RC,,,,,,outpatient,facility,,,2030,2030,129.72,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,609,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1522.5,,,percent of total billed charges,,,,,,1421,,,percent of total billed charges,,,,,,1421,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1319.5,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2030,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1415.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,,percent of total billed charges,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2030,,,fee schedule,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1725.5,,,percent of total billed charges,,,,,,1522.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 1200 66MM,12608,CDM,0278,RC,,,,,,inpatient,facility,,,2030,2030,913.5,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1624,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1522.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1227.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2030,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,1319.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 1200 66MM,12608,CDM,0278,RC,,,,,,outpatient,facility,,,2030,2030,129.72,2030,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1725.5,,,percent of total billed charges,,,,,,609,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,385.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1522.5,,,percent of total billed charges,,,,,,1421,,,percent of total billed charges,,,,,,1421,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1319.5,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2030,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1116.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1415.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1441.3,,,percent of total billed charges,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1421,,,percent of total billed charges,,,,,,1218,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1725.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2030,,,percent of total billed charges,,,,,,913.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2030,,,fee schedule,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,2030,,,percent of total billed charges,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1116.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2030,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1725.5,,,percent of total billed charges,,,,,,1522.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 26   7,12614,CDM,0278,RC,,,,,,inpatient,facility,,,833,833,374.85,833,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,666.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,624.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,458.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,503.55,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",591.43,,,percent of total billed charges,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,583.1,,,percent of total billed charges,,,,,,499.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,833,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,541.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 26   7,12614,CDM,0278,RC,,,,,,outpatient,facility,,,833,833,129.72,833,,541.45,,,percent of total billed charges,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,249.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,391.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,158.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,158.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,624.75,,,percent of total billed charges,,,,,,583.1,,,percent of total billed charges,,,,,,583.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,541.45,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,833,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,583.1,,,percent of total billed charges,,,,,,458.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,581.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,591.43,,,percent of total billed charges,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,583.1,,,percent of total billed charges,,,,,,499.8,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,833,,,fee schedule,,,,,,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,708.05,,,percent of total billed charges,,,,,,624.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 26   10,12615,CDM,0278,RC,,,,,,inpatient,facility,,,833,833,374.85,833,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,666.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,624.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,458.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,503.55,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",591.43,,,percent of total billed charges,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,583.1,,,percent of total billed charges,,,,,,499.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,833,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,541.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 26   10,12615,CDM,0278,RC,,,,,,outpatient,facility,,,833,833,129.72,833,,541.45,,,percent of total billed charges,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,249.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,391.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,158.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,158.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,624.75,,,percent of total billed charges,,,,,,583.1,,,percent of total billed charges,,,,,,583.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,541.45,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,833,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,583.1,,,percent of total billed charges,,,,,,458.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,581.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,591.43,,,percent of total billed charges,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,583.1,,,percent of total billed charges,,,,,,499.8,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,833,,,fee schedule,,,,,,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,708.05,,,percent of total billed charges,,,,,,624.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE STD 28   1.5 NC,12616,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE STD 28   1.5 NC,12616,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE STD 28   8.5 NC,12618,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE STD 28   8.5 NC,12618,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE STD 28   12.0 NC,12619,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE STD 28   12.0 NC,12619,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 28   15.5 NC,12620,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 28   15.5 NC,12620,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 32   1 NC,12621,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 32   1 NC,12621,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 32   5 NC,12622,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 32   5 NC,12622,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 32   9 NC,12623,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 32   9 NC,12623,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 32   13 NC,12624,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 32   13 NC,12624,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 32   17,12625,CDM,0278,RC,,,,,,inpatient,facility,,,833,833,374.85,833,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,666.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,624.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,458.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,503.55,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",591.43,,,percent of total billed charges,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,583.1,,,percent of total billed charges,,,,,,499.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,833,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,541.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 32   17,12625,CDM,0278,RC,,,,,,outpatient,facility,,,833,833,129.72,833,,541.45,,,percent of total billed charges,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,249.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,391.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,158.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,158.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,624.75,,,percent of total billed charges,,,,,,583.1,,,percent of total billed charges,,,,,,583.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,541.45,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,833,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,583.1,,,percent of total billed charges,,,,,,458.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,581.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,591.43,,,percent of total billed charges,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,583.1,,,percent of total billed charges,,,,,,499.8,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,833,,,fee schedule,,,,,,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,708.05,,,percent of total billed charges,,,,,,624.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP HIP FEM REVISON 4 X 200,12647,CDM,0278,RC,,,,,,inpatient,facility,,,11161,11161,5022.45,11161,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,9486.85,,,percent of total billed charges,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6138.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8928.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,8370.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6138.55,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6746.82,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",7924.31,,,percent of total billed charges,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7812.7,,,percent of total billed charges,,,,,,6696.6,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9486.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6138.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11161,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,8370.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,11161,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5022.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9486.85,,,percent of total billed charges,,,,,,7254.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP HIP FEM REVISON 4 X 200,12647,CDM,0278,RC,,,,,,outpatient,facility,,,11161,11161,129.72,11161,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,9486.85,,,percent of total billed charges,,,,,,3348.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6138.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2120.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2120.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8370.76,,,percent of total billed charges,,,,,,7812.7,,,percent of total billed charges,,,,,,7812.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7254.65,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,11161,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7812.7,,,percent of total billed charges,,,,,,6138.55,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,,percent of total billed charges,,,,,,7784.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,7924.31,,,percent of total billed charges,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7812.7,,,percent of total billed charges,,,,,,6696.6,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9486.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6138.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,,percent of total billed charges,,,,,,11161,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11161,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,8370.75,,,percent of total billed charges,,,,,,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,11161,,,percent of total billed charges,,,,,,5022.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8370.75,,,percent of total billed charges,,,,,,6138.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11161,,,fee schedule,,,,,,11161,,,percent of total billed charges,,,,,,11161,,,percent of total billed charges,,,,,,11161,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,9486.85,,,percent of total billed charges,,,,,,8370.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP HIP FEM REVISON 2 X 230,12648,CDM,0278,RC,,,,,,inpatient,facility,,,11161,11161,5022.45,11161,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,9486.85,,,percent of total billed charges,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6138.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8928.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,8370.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6138.55,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6746.82,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",7924.31,,,percent of total billed charges,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7812.7,,,percent of total billed charges,,,,,,6696.6,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9486.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6138.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11161,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,8370.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,11161,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5022.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9486.85,,,percent of total billed charges,,,,,,7254.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP HIP FEM REVISON 2 X 230,12648,CDM,0278,RC,,,,,,outpatient,facility,,,11161,11161,129.72,11161,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,9486.85,,,percent of total billed charges,,,,,,3348.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6138.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2120.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2120.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8370.76,,,percent of total billed charges,,,,,,7812.7,,,percent of total billed charges,,,,,,7812.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7254.65,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,11161,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7812.7,,,percent of total billed charges,,,,,,6138.55,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,,percent of total billed charges,,,,,,7784.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,7924.31,,,percent of total billed charges,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7812.7,,,percent of total billed charges,,,,,,6696.6,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9486.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6138.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6138.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,,percent of total billed charges,,,,,,11161,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11161,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,8370.75,,,percent of total billed charges,,,,,,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,11161,,,percent of total billed charges,,,,,,5022.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8370.75,,,percent of total billed charges,,,,,,6138.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11161,,,fee schedule,,,,,,11161,,,percent of total billed charges,,,,,,11161,,,percent of total billed charges,,,,,,11161,,,percent of total billed charges,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6138.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,11161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,9486.85,,,percent of total billed charges,,,,,,8370.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATCH PERI GUARD 8 X 14  i,1271,CDM,0278,RC,,,,,,inpatient,facility,,,1730.08,1730.08,778.54,1730.08,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1470.57,,,percent of total billed charges,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1384.06,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1297.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,951.54,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1045.83,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1228.36,,,percent of total billed charges,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1211.06,,,percent of total billed charges,,,,,,1038.05,,,percent of total billed charges,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1470.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,951.54,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1730.08,,,percent of total billed charges,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1297.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1730.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,778.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1470.57,,,percent of total billed charges,,,,,,1124.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATCH PERI GUARD 8 X 14  i,1271,CDM,0278,RC,,,,,,outpatient,facility,,,1730.08,1730.08,129.72,1730.08,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1470.57,,,percent of total billed charges,,,,,,519.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,328.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1297.56,,,percent of total billed charges,,,,,,1211.06,,,percent of total billed charges,,,,,,1211.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1124.55,,,percent of total billed charges,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1730.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1211.06,,,percent of total billed charges,,,,,,951.54,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1730.08,,,percent of total billed charges,,,,,,1206.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1228.36,,,percent of total billed charges,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1211.06,,,percent of total billed charges,,,,,,1038.05,,,percent of total billed charges,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1470.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,951.54,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1730.08,,,percent of total billed charges,,,,,,1730.08,,,percent of total billed charges,,,,,,951.54,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1730.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1730.08,,,percent of total billed charges,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1297.56,,,percent of total billed charges,,,,,,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1730.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1730.08,,,percent of total billed charges,,,,,,778.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1297.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1730.08,,,fee schedule,,,,,,1730.08,,,percent of total billed charges,,,,,,1730.08,,,percent of total billed charges,,,,,,1730.08,,,percent of total billed charges,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,951.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1730.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1470.57,,,percent of total billed charges,,,,,,1297.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX 5percent 0.3percent NACL 500 0725 03  i,12762,CDM,0258,RC,,,,,,inpatient,facility,,,17.5,17.5,7.88,17.5,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,12.25,,,percent of total billed charges,,,,,,10.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,17.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent 0.3percent NACL 500 0725 03  i,12762,CDM,0258,RC,,,,,,outpatient,facility,,,17.5,17.5,3.33,1016,,11.38,,,percent of total billed charges,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,5.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,13.12,,,percent of total billed charges,,,,,,12.25,,,percent of total billed charges,,,,,,12.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,11.38,,,percent of total billed charges,,,,,,4.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,17.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.35,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",12.25,,,percent of total billed charges,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,,,,,12.21,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,12.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,12.25,,,percent of total billed charges,,,,,,10.5,,,percent of total billed charges,,,,,,7.88,,,percent of total billed charges,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,,,,,17.5,,,percent of total billed charges,,,,,,7.53,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,17.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.12,,,percent of total billed charges,,,,,,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,17.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,17.5,,,percent of total billed charges,,,,,,7.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.5,,,fee schedule,,,,,,17.5,,,percent of total billed charges,,,,,,17.5,,,percent of total billed charges,,,,,,17.5,,,percent of total billed charges,,,,,,8.4,,,percent of total billed charges,,,,,,,,,,,,,,,10.32,,,percent of total billed charges,,,,,,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,17.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.88,,,percent of total billed charges,,,,,,13.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ENDOTRACH SHILEY N CUFF N DEHP 4.0MM,12779,CDM,0272,RC,,,,,,inpatient,facility,,,4.53,4.53,2.04,4.53,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ENDOTRACH SHILEY N CUFF N DEHP 4.0MM,12779,CDM,0272,RC,,,,,,outpatient,facility,,,4.53,4.53,0.86,1016,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.4,,,percent of total billed charges,,,,,,3.17,,,percent of total billed charges,,,,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,1.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.06,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,3.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,1.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,fee schedule,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.85,,,percent of total billed charges,,,,,,3.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CANNULA DLP AORTIC ROOT 14GA  i,1298,CDM,0272,RC,,,,,,inpatient,facility,,,1554,1554,699.3,1554,,,,,,,,,,,,,,,,,,,,1320.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1165.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1010.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1103.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1087.8,,,percent of total billed charges,,,,,,932.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1320.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1554,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1165.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1554,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,699.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1320.9,,,percent of total billed charges,,,,,,,,,,,,,,
CANNULA DLP AORTIC ROOT 14GA  i,1298,CDM,0272,RC,,,,,,outpatient,facility,,,1554,1554,129.72,1554,,1010.1,,,percent of total billed charges,,,,,,,,,,,,,,,1320.9,,,percent of total billed charges,,,,,,466.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,730.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,295.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,295.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1165.5,,,percent of total billed charges,,,,,,1087.8,,,percent of total billed charges,,,,,,1087.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1010.1,,,percent of total billed charges,,,,,,372.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1048.95,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1554,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,652.68,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1087.8,,,percent of total billed charges,,,,,,,,,,,,,,,1554,,,percent of total billed charges,,,,,,1083.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1103.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1087.8,,,percent of total billed charges,,,,,,932.4,,,percent of total billed charges,,,,,,699.3,,,percent of total billed charges,,,,,,,,,,,,,,,1320.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1554,,,percent of total billed charges,,,,,,1554,,,percent of total billed charges,,,,,,668.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1554,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1554,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1165.5,,,percent of total billed charges,,,,,,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1554,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1554,,,percent of total billed charges,,,,,,699.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1165.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1554,,,fee schedule,,,,,,1554,,,percent of total billed charges,,,,,,1554,,,percent of total billed charges,,,,,,1554,,,percent of total billed charges,,,,,,745.92,,,percent of total billed charges,,,,,,,,,,,,,,,916.86,,,percent of total billed charges,,,,,,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1554,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1320.9,,,percent of total billed charges,,,,,,1165.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE STRT GAMMA BLUNT BALL TIP 3.0 X 750,13030,CDM,0272,RC,,,,,,inpatient,facility,,,660.45,660.45,297.2,660.45,,,,,,,,,,,,,,,,,,,,561.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,468.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,462.32,,,percent of total billed charges,,,,,,396.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,561.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,660.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,297.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,561.38,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE STRT GAMMA BLUNT BALL TIP 3.0 X 750,13030,CDM,0272,RC,,,,,,outpatient,facility,,,660.45,660.45,125.49,1016,,429.29,,,percent of total billed charges,,,,,,,,,,,,,,,561.38,,,percent of total billed charges,,,,,,198.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,310.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,125.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,125.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,495.33,,,percent of total billed charges,,,,,,462.31,,,percent of total billed charges,,,,,,462.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,429.29,,,percent of total billed charges,,,,,,158.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",445.8,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,660.45,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,277.39,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",462.31,,,percent of total billed charges,,,,,,,,,,,,,,,660.45,,,percent of total billed charges,,,,,,460.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,468.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,462.32,,,percent of total billed charges,,,,,,396.27,,,percent of total billed charges,,,,,,297.2,,,percent of total billed charges,,,,,,,,,,,,,,,561.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660.45,,,percent of total billed charges,,,,,,660.45,,,percent of total billed charges,,,,,,283.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,660.45,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,660.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.34,,,percent of total billed charges,,,,,,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,660.45,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,660.45,,,percent of total billed charges,,,,,,297.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660.45,,,fee schedule,,,,,,660.45,,,percent of total billed charges,,,,,,660.45,,,percent of total billed charges,,,,,,660.45,,,percent of total billed charges,,,,,,317.02,,,percent of total billed charges,,,,,,,,,,,,,,,389.67,,,percent of total billed charges,,,,,,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,660.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,561.38,,,percent of total billed charges,,,,,,495.34,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PERFORATOR ACRA CUT DGR O 14 11MM  i,13692,CDM,0272,RC,,,,,,inpatient,facility,,,738.5,738.5,332.32,738.5,,,,,,,,,,,,,,,,,,,,627.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,516.95,,,percent of total billed charges,,,,,,443.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,627.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,738.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,738.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,627.72,,,percent of total billed charges,,,,,,,,,,,,,,
PERFORATOR ACRA CUT DGR O 14 11MM  i,13692,CDM,0272,RC,,,,,,outpatient,facility,,,738.5,738.5,129.72,1016,,480.02,,,percent of total billed charges,,,,,,,,,,,,,,,627.72,,,percent of total billed charges,,,,,,221.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,347.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,140.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,140.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,553.88,,,percent of total billed charges,,,,,,516.95,,,percent of total billed charges,,,,,,516.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,480.03,,,percent of total billed charges,,,,,,177.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",498.49,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,738.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,310.17,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",516.95,,,percent of total billed charges,,,,,,,,,,,,,,,738.5,,,percent of total billed charges,,,,,,515.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,524.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,516.95,,,percent of total billed charges,,,,,,443.1,,,percent of total billed charges,,,,,,332.32,,,percent of total billed charges,,,,,,,,,,,,,,,627.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,738.5,,,percent of total billed charges,,,,,,738.5,,,percent of total billed charges,,,,,,317.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,738.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,738.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.88,,,percent of total billed charges,,,,,,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,738.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,738.5,,,percent of total billed charges,,,,,,332.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,738.5,,,fee schedule,,,,,,738.5,,,percent of total billed charges,,,,,,738.5,,,percent of total billed charges,,,,,,738.5,,,percent of total billed charges,,,,,,354.48,,,percent of total billed charges,,,,,,,,,,,,,,,435.71,,,percent of total billed charges,,,,,,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,738.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,627.72,,,percent of total billed charges,,,,,,553.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TRAY TRACH INTRO SET BLUE RHINO G2 MULTI PERC C PT,13750,CDM,0272,RC,,,,,,inpatient,facility,,,1790.6,1790.6,805.77,1790.6,,,,,,,,,,,,,,,,,,,,1522.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1342.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1271.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1253.42,,,percent of total billed charges,,,,,,1074.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1522.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1790.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1342.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1790.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,805.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.01,,,percent of total billed charges,,,,,,,,,,,,,,
TRAY TRACH INTRO SET BLUE RHINO G2 MULTI PERC C PT,13750,CDM,0272,RC,,,,,,outpatient,facility,,,1790.6,1790.6,129.72,1790.6,,1163.89,,,percent of total billed charges,,,,,,,,,,,,,,,1522.01,,,percent of total billed charges,,,,,,537.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,841.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,340.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,340.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1342.94,,,percent of total billed charges,,,,,,1253.42,,,percent of total billed charges,,,,,,1253.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1163.89,,,percent of total billed charges,,,,,,429.74,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1208.66,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1790.6,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,752.05,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1253.42,,,percent of total billed charges,,,,,,,,,,,,,,,1790.6,,,percent of total billed charges,,,,,,1248.94,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1271.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1253.42,,,percent of total billed charges,,,,,,1074.36,,,percent of total billed charges,,,,,,805.77,,,percent of total billed charges,,,,,,,,,,,,,,,1522.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1790.6,,,percent of total billed charges,,,,,,1790.6,,,percent of total billed charges,,,,,,769.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1790.6,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1790.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1342.95,,,percent of total billed charges,,,,,,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1790.6,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1790.6,,,percent of total billed charges,,,,,,805.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1342.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1790.6,,,fee schedule,,,,,,1790.6,,,percent of total billed charges,,,,,,1790.6,,,percent of total billed charges,,,,,,1790.6,,,percent of total billed charges,,,,,,859.49,,,percent of total billed charges,,,,,,,,,,,,,,,1056.45,,,percent of total billed charges,,,,,,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1790.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1522.01,,,percent of total billed charges,,,,,,1342.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FINGER TRAP ALLEN MESH XLG  i,13764,CDM,0270,RC,,,,,,inpatient,facility,,,82.81,82.81,37.26,82.81,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.97,,,percent of total billed charges,,,,,,49.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,
FINGER TRAP ALLEN MESH XLG  i,13764,CDM,0270,RC,,,,,,outpatient,facility,,,82.81,82.81,15.73,1016,,53.83,,,percent of total billed charges,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,24.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,38.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,15.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,62.11,,,percent of total billed charges,,,,,,57.97,,,percent of total billed charges,,,,,,57.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,53.83,,,percent of total billed charges,,,,,,19.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",55.9,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,82.81,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.78,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",57.97,,,percent of total billed charges,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,57.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,58.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,57.97,,,percent of total billed charges,,,,,,49.69,,,percent of total billed charges,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,70.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,35.61,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,82.81,,,percent of total billed charges,,,,,,37.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.81,,,fee schedule,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,82.81,,,percent of total billed charges,,,,,,39.75,,,percent of total billed charges,,,,,,,,,,,,,,,48.86,,,percent of total billed charges,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,82.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.39,,,percent of total billed charges,,,,,,62.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PORT POWERPORT DUO MRI OPEN END DBL LMN CATH 9.5FR,13783,CDM,0278,RC,,,,,,inpatient,facility,,,690,690,310.5,690,,,,,,,,,,,,,,,,,,,,586.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,552,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,517.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,417.11,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",489.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,483,,,percent of total billed charges,,,,,,414,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,586.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,379.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,517.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,690,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,310.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,586.5,,,percent of total billed charges,,,,,,448.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PORT POWERPORT DUO MRI OPEN END DBL LMN CATH 9.5FR,13783,CDM,0278,RC,,,,,,outpatient,facility,,,690,690,129.72,690,,448.5,,,percent of total billed charges,,,,,,,,,,,,,,,586.5,,,percent of total billed charges,,,,,,207,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,324.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,131.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,131.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,379.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,379.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,379.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,517.5,,,percent of total billed charges,,,,,,483,,,percent of total billed charges,,,,,,483,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,448.5,,,percent of total billed charges,,,,,,379.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,690,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,289.8,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",483,,,percent of total billed charges,,,,,,,,,,,,,,,690,,,percent of total billed charges,,,,,,481.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,489.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,483,,,percent of total billed charges,,,,,,414,,,percent of total billed charges,,,,,,310.5,,,percent of total billed charges,,,,,,,,,,,,,,,586.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,690,,,percent of total billed charges,,,,,,690,,,percent of total billed charges,,,,,,379.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,690,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,690,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,517.5,,,percent of total billed charges,,,,,,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,690,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,690,,,percent of total billed charges,,,,,,310.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,517.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690,,,fee schedule,,,,,,690,,,percent of total billed charges,,,,,,690,,,percent of total billed charges,,,,,,690,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,690,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,586.5,,,percent of total billed charges,,,,,,517.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 34 X 30  c,1381,CDM,0278,RC,,,,,,inpatient,facility,,,1229.92,1229.92,553.46,1229.92,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1045.43,,,percent of total billed charges,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,922.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,676.46,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,743.49,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",873.24,,,percent of total billed charges,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,860.94,,,percent of total billed charges,,,,,,737.95,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1045.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.92,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,922.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1229.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,553.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1045.43,,,percent of total billed charges,,,,,,799.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 34 X 30  c,1381,CDM,0278,RC,,,,,,outpatient,facility,,,1229.92,1229.92,129.72,1229.92,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1045.43,,,percent of total billed charges,,,,,,368.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,233.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,233.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,922.44,,,percent of total billed charges,,,,,,860.94,,,percent of total billed charges,,,,,,860.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,799.45,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1229.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,860.94,,,percent of total billed charges,,,,,,676.46,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,,percent of total billed charges,,,,,,857.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,873.24,,,percent of total billed charges,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,860.94,,,percent of total billed charges,,,,,,737.95,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1045.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.46,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,,percent of total billed charges,,,,,,1229.92,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,922.44,,,percent of total billed charges,,,,,,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1229.92,,,percent of total billed charges,,,,,,553.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,922.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1229.92,,,fee schedule,,,,,,1229.92,,,percent of total billed charges,,,,,,1229.92,,,percent of total billed charges,,,,,,1229.92,,,percent of total billed charges,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,676.46,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1229.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1045.43,,,percent of total billed charges,,,,,,922.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 16 X 30,1382,CDM,0278,RC,,,,,,inpatient,facility,,,1182.08,1182.08,531.94,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,886.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,714.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,768.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 16 X 30,1382,CDM,0278,RC,,,,,,outpatient,facility,,,1182.08,1182.08,129.72,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,354.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,886.56,,,percent of total billed charges,,,,,,827.46,,,percent of total billed charges,,,,,,827.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,768.35,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1182.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,824.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,,percent of total billed charges,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1182.08,,,fee schedule,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.77,,,percent of total billed charges,,,,,,886.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 24 X 30,1383,CDM,0278,RC,,,,,,inpatient,facility,,,1182.08,1182.08,531.94,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,886.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,714.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,768.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 24 X 30,1383,CDM,0278,RC,,,,,,outpatient,facility,,,1182.08,1182.08,129.72,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,354.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,886.56,,,percent of total billed charges,,,,,,827.46,,,percent of total billed charges,,,,,,827.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,768.35,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1182.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,824.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,,percent of total billed charges,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1182.08,,,fee schedule,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.77,,,percent of total billed charges,,,,,,886.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD BIF 14 X 8 X 40  c,13842,CDM,0278,RC,,,,,,inpatient,facility,,,1513.08,1513.08,680.89,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1210.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1134.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,914.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,983.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD BIF 14 X 8 X 40  c,13842,CDM,0278,RC,,,,,,outpatient,facility,,,1513.08,1513.08,129.72,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,453.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1134.81,,,percent of total billed charges,,,,,,1059.16,,,percent of total billed charges,,,,,,1059.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,983.5,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1513.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1055.37,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,,percent of total billed charges,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1513.08,,,fee schedule,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1286.12,,,percent of total billed charges,,,,,,1134.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE TRACH N CUFF 5.0M 8F  i,13896,CDM,0272,RC,,,,,,inpatient,facility,,,4.53,4.53,2.04,4.53,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE TRACH N CUFF 5.0M 8F  i,13896,CDM,0272,RC,,,,,,outpatient,facility,,,4.53,4.53,0.86,1016,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.4,,,percent of total billed charges,,,,,,3.17,,,percent of total billed charges,,,,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,1.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.06,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,3.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,1.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,fee schedule,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.85,,,percent of total billed charges,,,,,,3.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE ZIM PLAIN STRL.062  i,13901,CDM,0272,RC,,,,,,inpatient,facility,,,46.86,46.86,21.09,46.86,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.8,,,percent of total billed charges,,,,,,28.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE ZIM PLAIN STRL.062  i,13901,CDM,0272,RC,,,,,,outpatient,facility,,,46.86,46.86,8.9,1016,,30.46,,,percent of total billed charges,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,14.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.14,,,percent of total billed charges,,,,,,32.8,,,percent of total billed charges,,,,,,32.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.46,,,percent of total billed charges,,,,,,11.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",31.63,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.86,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.68,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.8,,,percent of total billed charges,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,32.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.8,,,percent of total billed charges,,,,,,28.12,,,percent of total billed charges,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,20.15,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,,percent of total billed charges,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,fee schedule,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,22.49,,,percent of total billed charges,,,,,,,,,,,,,,,27.65,,,percent of total billed charges,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.83,,,percent of total billed charges,,,,,,35.15,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ELECTRODE DISP LNG TERM ADULT,13967,CDM,0272,RC,,,,,,inpatient,facility,,,0.86,0.86,0.39,0.86,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,
ELECTRODE DISP LNG TERM ADULT,13967,CDM,0272,RC,,,,,,outpatient,facility,,,0.86,0.86,0.16,1016,,0.56,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,0.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,0.64,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.56,,,percent of total billed charges,,,,,,0.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.58,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,0.86,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.6,,,percent of total billed charges,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,0.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,0.52,,,percent of total billed charges,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,0.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,0.86,,,percent of total billed charges,,,,,,0.37,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.64,,,percent of total billed charges,,,,,,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.86,,,percent of total billed charges,,,,,,0.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.86,,,fee schedule,,,,,,0.86,,,percent of total billed charges,,,,,,0.86,,,percent of total billed charges,,,,,,0.86,,,percent of total billed charges,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,0.51,,,percent of total billed charges,,,,,,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,0.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.73,,,percent of total billed charges,,,,,,0.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATCH FELT TEFLON  4 X 4  i,1398,CDM,0278,RC,,,,,,inpatient,facility,,,467.2,467.2,210.24,467.2,,,,,,,,,,,,,,,,,,,,397.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.42,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",331.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,327.04,,,percent of total billed charges,,,,,,280.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,397.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,467.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,210.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.12,,,percent of total billed charges,,,,,,303.68,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATCH FELT TEFLON  4 X 4  i,1398,CDM,0278,RC,,,,,,outpatient,facility,,,467.2,467.2,88.77,467.2,,303.68,,,percent of total billed charges,,,,,,,,,,,,,,,397.12,,,percent of total billed charges,,,,,,140.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,88.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,88.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,256.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,350.4,,,percent of total billed charges,,,,,,327.04,,,percent of total billed charges,,,,,,327.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,303.68,,,percent of total billed charges,,,,,,112.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,467.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",327.04,,,percent of total billed charges,,,,,,,,,,,,,,,467.2,,,percent of total billed charges,,,,,,325.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,331.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,327.04,,,percent of total billed charges,,,,,,280.32,,,percent of total billed charges,,,,,,210.24,,,percent of total billed charges,,,,,,,,,,,,,,,397.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.2,,,percent of total billed charges,,,,,,467.2,,,percent of total billed charges,,,,,,200.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,467.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,467.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.4,,,percent of total billed charges,,,,,,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,467.2,,,percent of total billed charges,,,,,,210.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.2,,,fee schedule,,,,,,467.2,,,percent of total billed charges,,,,,,467.2,,,percent of total billed charges,,,,,,467.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,467.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,397.12,,,percent of total billed charges,,,,,,350.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH FEM ART 18G 4 1 2,1404,CDM,0272,RC,,,,,,inpatient,facility,,,43.82,43.82,19.72,43.82,,,,,,,,,,,,,,,,,,,,37.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,30.67,,,percent of total billed charges,,,,,,26.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,37.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,43.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,19.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.25,,,percent of total billed charges,,,,,,,,,,,,,,
CATH FEM ART 18G 4 1 2,1404,CDM,0272,RC,,,,,,outpatient,facility,,,43.82,43.82,8.33,1016,,28.48,,,percent of total billed charges,,,,,,,,,,,,,,,37.25,,,percent of total billed charges,,,,,,13.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,20.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,32.87,,,percent of total billed charges,,,,,,30.67,,,percent of total billed charges,,,,,,30.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,28.48,,,percent of total billed charges,,,,,,10.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",29.58,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,43.82,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,18.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",30.67,,,percent of total billed charges,,,,,,,,,,,,,,,43.82,,,percent of total billed charges,,,,,,30.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,31.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,30.67,,,percent of total billed charges,,,,,,26.29,,,percent of total billed charges,,,,,,19.72,,,percent of total billed charges,,,,,,,,,,,,,,,37.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.82,,,percent of total billed charges,,,,,,43.82,,,percent of total billed charges,,,,,,18.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,43.82,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,43.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.86,,,percent of total billed charges,,,,,,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,43.82,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,43.82,,,percent of total billed charges,,,,,,19.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.82,,,fee schedule,,,,,,43.82,,,percent of total billed charges,,,,,,43.82,,,percent of total billed charges,,,,,,43.82,,,percent of total billed charges,,,,,,21.03,,,percent of total billed charges,,,,,,,,,,,,,,,25.85,,,percent of total billed charges,,,,,,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,43.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.25,,,percent of total billed charges,,,,,,32.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC GRAND SUITE NO TELEMETRY,14090020,CDM,0140,RC,,,,,,inpatient,facility,,,3603.6,3603.6,295.98,7000,,3538,,,per diem,,,,,,3603.6,,,fee schedule,,,,,,3063.06,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3603.6,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3603.6,,,case rate,,,,,,3603.6,,,case rate,,,,,,3603.6,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3603.6,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2522.52,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1801.8,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1801.8,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2342.34,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3603.6,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2522.52,,,percent of total billed charges,,,,,,,,,,,,,,,3603.6,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2558.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2522.52,,,percent of total billed charges,,,,,,2162.16,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,3063.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3603.6,,,percent of total billed charges,,,,,,3603.6,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.16,,,percent of total billed charges,,,,,,3603.6,,,fee schedule,,,,,,3603.6,,,fee schedule,,,,,,3603.6,,,fee schedule,,,,,,3603.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3603.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2702.7,,,percent of total billed charges,,,,,,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3603.6,,,percent of total billed charges,,,,,,,,,,,,,,,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3603.6,,,percent of total billed charges,,,,,,1621.62,,,percent of total billed charges,,,,,,,,,,,,,,,3603.6,,,fee schedule,,,,,,,,,,,,,,,3603.6,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3603.6,,,fee schedule,,,,,,,,,,,,,,,3603.6,,,fee schedule,,,,,,,,,,,,,,,2162.16,,,percent of total billed charges,,,,,,3603.6,,,percent of total billed charges,,,,,,2162.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3063.06,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC GRAND SUITE   NO TELEMETRY,14090021,CDM,0140,RC,,,,,,inpatient,facility,,,3603.6,3603.6,295.98,7000,,3538,,,per diem,,,,,,3603.6,,,fee schedule,,,,,,3063.06,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3603.6,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3603.6,,,case rate,,,,,,3603.6,,,case rate,,,,,,3603.6,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3603.6,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2522.52,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1801.8,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1801.8,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2342.34,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3603.6,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2522.52,,,percent of total billed charges,,,,,,,,,,,,,,,3603.6,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2558.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2522.52,,,percent of total billed charges,,,,,,2162.16,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,3063.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3603.6,,,percent of total billed charges,,,,,,3603.6,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.16,,,percent of total billed charges,,,,,,3603.6,,,fee schedule,,,,,,3603.6,,,fee schedule,,,,,,3603.6,,,fee schedule,,,,,,3603.6,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3603.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2702.7,,,percent of total billed charges,,,,,,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3603.6,,,percent of total billed charges,,,,,,,,,,,,,,,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3603.6,,,percent of total billed charges,,,,,,1621.62,,,percent of total billed charges,,,,,,,,,,,,,,,3603.6,,,fee schedule,,,,,,,,,,,,,,,3603.6,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3603.6,,,fee schedule,,,,,,,,,,,,,,,3603.6,,,fee schedule,,,,,,,,,,,,,,,2162.16,,,percent of total billed charges,,,,,,3603.6,,,percent of total billed charges,,,,,,2162.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3603.6,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3063.06,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
GWIRE DX EMERALD FC J STD .025 X 3 X 150  i,1412,CDM,0272,RC,,,,,,inpatient,facility,,,34.12,34.12,15.35,34.12,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,percent of total billed charges,,,,,,20.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,34.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE DX EMERALD FC J STD .025 X 3 X 150  i,1412,CDM,0272,RC,,,,,,outpatient,facility,,,34.12,34.12,6.48,1016,,22.18,,,percent of total billed charges,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,10.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,25.59,,,percent of total billed charges,,,,,,23.88,,,percent of total billed charges,,,,,,23.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,22.18,,,percent of total billed charges,,,,,,8.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",23.03,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.33,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",23.88,,,percent of total billed charges,,,,,,,,,,,,,,,34.12,,,percent of total billed charges,,,,,,23.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,24.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.88,,,percent of total billed charges,,,,,,20.47,,,percent of total billed charges,,,,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.12,,,percent of total billed charges,,,,,,34.12,,,percent of total billed charges,,,,,,14.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,34.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,34.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.59,,,percent of total billed charges,,,,,,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.12,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.12,,,percent of total billed charges,,,,,,15.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.12,,,fee schedule,,,,,,34.12,,,percent of total billed charges,,,,,,34.12,,,percent of total billed charges,,,,,,34.12,,,percent of total billed charges,,,,,,16.38,,,percent of total billed charges,,,,,,,,,,,,,,,20.13,,,percent of total billed charges,,,,,,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29,,,percent of total billed charges,,,,,,25.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE SPRING DUOFLEX .025 X 17 13 16,1413,CDM,0272,RC,,,,,,inpatient,facility,,,34.02,34.02,15.31,34.02,,,,,,,,,,,,,,,,,,,,28.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,20.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,28.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,34.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.92,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE SPRING DUOFLEX .025 X 17 13 16,1413,CDM,0272,RC,,,,,,outpatient,facility,,,34.02,34.02,6.46,1016,,22.11,,,percent of total billed charges,,,,,,,,,,,,,,,28.92,,,percent of total billed charges,,,,,,10.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,25.51,,,percent of total billed charges,,,,,,23.81,,,percent of total billed charges,,,,,,23.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,22.11,,,percent of total billed charges,,,,,,8.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",22.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.02,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",23.81,,,percent of total billed charges,,,,,,,,,,,,,,,34.02,,,percent of total billed charges,,,,,,23.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,24.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.81,,,percent of total billed charges,,,,,,20.41,,,percent of total billed charges,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,28.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.02,,,percent of total billed charges,,,,,,34.02,,,percent of total billed charges,,,,,,14.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,34.02,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,34.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.02,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,34.02,,,percent of total billed charges,,,,,,15.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.02,,,fee schedule,,,,,,34.02,,,percent of total billed charges,,,,,,34.02,,,percent of total billed charges,,,,,,34.02,,,percent of total billed charges,,,,,,16.33,,,percent of total billed charges,,,,,,,,,,,,,,,20.07,,,percent of total billed charges,,,,,,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,34.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.92,,,percent of total billed charges,,,,,,25.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE SYN 0.6X70,14142,CDM,0272,RC,,,,,,inpatient,facility,,,25.43,25.43,11.44,25.43,,,,,,,,,,,,,,,,,,,,21.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,17.8,,,percent of total billed charges,,,,,,15.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,21.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,25.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,11.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.62,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE SYN 0.6X70,14142,CDM,0272,RC,,,,,,outpatient,facility,,,25.43,25.43,4.83,1016,,16.53,,,percent of total billed charges,,,,,,,,,,,,,,,21.62,,,percent of total billed charges,,,,,,7.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,11.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,4.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,19.08,,,percent of total billed charges,,,,,,17.8,,,percent of total billed charges,,,,,,17.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,16.53,,,percent of total billed charges,,,,,,6.1,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",17.17,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,25.43,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,10.68,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",17.8,,,percent of total billed charges,,,,,,,,,,,,,,,25.43,,,percent of total billed charges,,,,,,17.74,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,18.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,17.8,,,percent of total billed charges,,,,,,15.26,,,percent of total billed charges,,,,,,11.44,,,percent of total billed charges,,,,,,,,,,,,,,,21.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.43,,,percent of total billed charges,,,,,,25.43,,,percent of total billed charges,,,,,,10.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,25.43,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,25.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.07,,,percent of total billed charges,,,,,,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,25.43,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,25.43,,,percent of total billed charges,,,,,,11.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.43,,,fee schedule,,,,,,25.43,,,percent of total billed charges,,,,,,25.43,,,percent of total billed charges,,,,,,25.43,,,percent of total billed charges,,,,,,12.21,,,percent of total billed charges,,,,,,,,,,,,,,,15,,,percent of total billed charges,,,,,,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,25.43,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,21.62,,,percent of total billed charges,,,,,,19.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS CR 2.0 X 22,14143,CDM,0278,RC,,,,,,inpatient,facility,,,61.7,61.7,27.77,61.7,,,,,,,,,,,,,,,,,,,,52.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.36,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,46.28,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",43.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,43.19,,,percent of total billed charges,,,,,,37.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,61.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,27.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.44,,,percent of total billed charges,,,,,,40.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS CR 2.0 X 22,14143,CDM,0278,RC,,,,,,outpatient,facility,,,61.7,61.7,11.72,138.8,,40.1,,,percent of total billed charges,,,,,,,,,,,,,,,52.44,,,percent of total billed charges,,,,,,18.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,11.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,33.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.28,,,percent of total billed charges,,,,,,43.19,,,percent of total billed charges,,,,,,43.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,40.11,,,percent of total billed charges,,,,,,14.81,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,61.7,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,25.91,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",43.19,,,percent of total billed charges,,,,,,,,,,,,,,,61.7,,,percent of total billed charges,,,,,,43.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,43.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,43.19,,,percent of total billed charges,,,,,,37.02,,,percent of total billed charges,,,,,,27.77,,,percent of total billed charges,,,,,,,,,,,,,,,52.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.7,,,percent of total billed charges,,,,,,61.7,,,percent of total billed charges,,,,,,26.53,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,61.7,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,61.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.28,,,percent of total billed charges,,,,,,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.7,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,61.7,,,percent of total billed charges,,,,,,27.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.7,,,fee schedule,,,,,,61.7,,,percent of total billed charges,,,,,,61.7,,,percent of total billed charges,,,,,,61.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,61.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,52.44,,,percent of total billed charges,,,,,,46.27,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 8 X 60  c,14196,CDM,0278,RC,,,,,,inpatient,facility,,,1182.08,1182.08,531.94,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,886.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,714.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,768.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 8 X 60  c,14196,CDM,0278,RC,,,,,,outpatient,facility,,,1182.08,1182.08,129.72,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,354.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,886.56,,,percent of total billed charges,,,,,,827.46,,,percent of total billed charges,,,,,,827.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,768.35,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1182.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,824.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,,percent of total billed charges,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1182.08,,,fee schedule,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.77,,,percent of total billed charges,,,,,,886.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 10 X 60,14197,CDM,0278,RC,,,,,,inpatient,facility,,,1182.08,1182.08,531.94,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,886.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,714.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,768.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 10 X 60,14197,CDM,0278,RC,,,,,,outpatient,facility,,,1182.08,1182.08,129.72,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,354.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,886.56,,,percent of total billed charges,,,,,,827.46,,,percent of total billed charges,,,,,,827.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,768.35,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1182.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,824.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,,percent of total billed charges,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1182.08,,,fee schedule,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.77,,,percent of total billed charges,,,,,,886.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 12 X 30,14198,CDM,0278,RC,,,,,,inpatient,facility,,,1182.08,1182.08,531.94,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,886.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,714.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,768.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 12 X 30,14198,CDM,0278,RC,,,,,,outpatient,facility,,,1182.08,1182.08,129.72,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,354.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,886.56,,,percent of total billed charges,,,,,,827.46,,,percent of total billed charges,,,,,,827.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,768.35,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1182.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,824.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,,percent of total billed charges,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1182.08,,,fee schedule,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.77,,,percent of total billed charges,,,,,,886.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD BIF 20 X 10 X 40  c,14200,CDM,0278,RC,,,,,,inpatient,facility,,,1513.08,1513.08,680.89,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1210.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1134.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,914.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,983.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD BIF 20 X 10 X 40  c,14200,CDM,0278,RC,,,,,,outpatient,facility,,,1513.08,1513.08,129.72,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,453.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1134.81,,,percent of total billed charges,,,,,,1059.16,,,percent of total billed charges,,,,,,1059.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,983.5,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1513.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1055.37,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,,percent of total billed charges,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1513.08,,,fee schedule,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1286.12,,,percent of total billed charges,,,,,,1134.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH EMBL FOGARTY 3FR 80CM PK 5  i,14239,CDM,0272,RC,,,,,,inpatient,facility,,,214.65,214.65,96.59,214.65,,,,,,,,,,,,,,,,,,,,182.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.26,,,percent of total billed charges,,,,,,128.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,182.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,214.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,96.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.45,,,percent of total billed charges,,,,,,,,,,,,,,
CATH EMBL FOGARTY 3FR 80CM PK 5  i,14239,CDM,0272,RC,,,,,,outpatient,facility,,,214.65,214.65,40.78,1016,,139.52,,,percent of total billed charges,,,,,,,,,,,,,,,182.45,,,percent of total billed charges,,,,,,64.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,100.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,40.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,40.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,160.99,,,percent of total billed charges,,,,,,150.25,,,percent of total billed charges,,,,,,150.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,139.52,,,percent of total billed charges,,,,,,51.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",144.89,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,214.65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,90.15,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",150.25,,,percent of total billed charges,,,,,,,,,,,,,,,214.65,,,percent of total billed charges,,,,,,149.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,152.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.26,,,percent of total billed charges,,,,,,128.79,,,percent of total billed charges,,,,,,96.59,,,percent of total billed charges,,,,,,,,,,,,,,,182.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.65,,,percent of total billed charges,,,,,,214.65,,,percent of total billed charges,,,,,,92.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,214.65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,214.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.99,,,percent of total billed charges,,,,,,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,214.65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,214.65,,,percent of total billed charges,,,,,,96.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.65,,,fee schedule,,,,,,214.65,,,percent of total billed charges,,,,,,214.65,,,percent of total billed charges,,,,,,214.65,,,percent of total billed charges,,,,,,103.03,,,percent of total billed charges,,,,,,,,,,,,,,,126.64,,,percent of total billed charges,,,,,,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,214.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.45,,,percent of total billed charges,,,,,,160.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC LandD HI DELUXE PRIVATE ROOM,14290021,CDM,0142,RC,,,,,,inpatient,facility,,,3809.52,3809.52,295.98,7000,,3538,,,per diem,,,,,,3809.52,,,fee schedule,,,,,,3238.09,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3809.52,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3809.52,,,case rate,,,,,,3809.52,,,case rate,,,,,,3809.52,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3809.52,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2666.66,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1904.76,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1904.76,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2476.19,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3809.52,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2666.66,,,percent of total billed charges,,,,,,,,,,,,,,,3809.52,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2704.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2666.66,,,percent of total billed charges,,,,,,2285.71,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,3238.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3809.52,,,percent of total billed charges,,,,,,3809.52,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2285.71,,,percent of total billed charges,,,,,,3809.52,,,fee schedule,,,,,,3809.52,,,fee schedule,,,,,,3809.52,,,fee schedule,,,,,,3809.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3809.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2857.14,,,percent of total billed charges,,,,,,3809.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3809.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3809.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3809.52,,,percent of total billed charges,,,,,,,,,,,,,,,3809.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3809.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3809.52,,,percent of total billed charges,,,,,,1714.28,,,percent of total billed charges,,,,,,,,,,,,,,,3809.52,,,fee schedule,,,,,,,,,,,,,,,3809.52,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3809.52,,,fee schedule,,,,,,,,,,,,,,,3809.52,,,fee schedule,,,,,,,,,,,,,,,2285.71,,,percent of total billed charges,,,,,,3809.52,,,percent of total billed charges,,,,,,2285.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3809.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3809.52,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3238.09,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC LandD MID DELUXE PRIVATE ROOM,14290022,CDM,0142,RC,,,,,,inpatient,facility,,,3637.92,3637.92,295.98,7000,,3538,,,per diem,,,,,,3637.92,,,fee schedule,,,,,,3092.23,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3637.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3637.92,,,case rate,,,,,,3637.92,,,case rate,,,,,,3637.92,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3637.92,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2546.54,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1818.96,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1818.96,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2364.65,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3637.92,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2546.54,,,percent of total billed charges,,,,,,,,,,,,,,,3637.92,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2582.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2546.54,,,percent of total billed charges,,,,,,2182.75,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,3092.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3637.92,,,percent of total billed charges,,,,,,3637.92,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2182.75,,,percent of total billed charges,,,,,,3637.92,,,fee schedule,,,,,,3637.92,,,fee schedule,,,,,,3637.92,,,fee schedule,,,,,,3637.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3637.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2728.44,,,percent of total billed charges,,,,,,3637.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3637.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3637.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3637.92,,,percent of total billed charges,,,,,,,,,,,,,,,3637.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3637.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3637.92,,,percent of total billed charges,,,,,,1637.06,,,percent of total billed charges,,,,,,,,,,,,,,,3637.92,,,fee schedule,,,,,,,,,,,,,,,3637.92,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3637.92,,,fee schedule,,,,,,,,,,,,,,,3637.92,,,fee schedule,,,,,,,,,,,,,,,2182.75,,,percent of total billed charges,,,,,,3637.92,,,percent of total billed charges,,,,,,2182.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3637.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3637.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3092.23,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC LandD JR DELUXE PRIVATE ROOM,14290023,CDM,0142,RC,,,,,,inpatient,facility,,,3552.12,3552.12,295.98,7000,,3538,,,per diem,,,,,,3552.12,,,fee schedule,,,,,,3019.3,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3552.12,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3552.12,,,case rate,,,,,,3552.12,,,case rate,,,,,,3552.12,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3552.12,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2486.48,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1776.06,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1776.06,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2308.88,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3552.12,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2486.48,,,percent of total billed charges,,,,,,,,,,,,,,,3552.12,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2522.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2486.48,,,percent of total billed charges,,,,,,2131.27,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,3019.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3552.12,,,percent of total billed charges,,,,,,3552.12,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2131.27,,,percent of total billed charges,,,,,,3552.12,,,fee schedule,,,,,,3552.12,,,fee schedule,,,,,,3552.12,,,fee schedule,,,,,,3552.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3552.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2664.09,,,percent of total billed charges,,,,,,3552.12,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3552.12,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3552.12,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3552.12,,,percent of total billed charges,,,,,,,,,,,,,,,3552.12,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3552.12,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3552.12,,,percent of total billed charges,,,,,,1598.45,,,percent of total billed charges,,,,,,,,,,,,,,,3552.12,,,fee schedule,,,,,,,,,,,,,,,3552.12,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3552.12,,,fee schedule,,,,,,,,,,,,,,,3552.12,,,fee schedule,,,,,,,,,,,,,,,2131.27,,,percent of total billed charges,,,,,,3552.12,,,percent of total billed charges,,,,,,2131.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3552.12,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3552.12,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3019.3,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC LandD PRIVATE SUITE,14295005,CDM,0142,RC,,,,,,inpatient,facility,,,4190.48,4190.48,295.98,7000,,3538,,,per diem,,,,,,4190.48,,,fee schedule,,,,,,3561.91,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4190.48,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4190.48,,,case rate,,,,,,4190.48,,,case rate,,,,,,4190.48,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4190.48,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2933.34,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2095.24,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2095.24,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2723.81,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4190.48,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2933.34,,,percent of total billed charges,,,,,,,,,,,,,,,4190.48,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2975.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2933.34,,,percent of total billed charges,,,,,,2514.29,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,3561.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4190.48,,,percent of total billed charges,,,,,,4190.48,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2514.29,,,percent of total billed charges,,,,,,4190.48,,,fee schedule,,,,,,4190.48,,,fee schedule,,,,,,4190.48,,,fee schedule,,,,,,4190.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4190.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3142.86,,,percent of total billed charges,,,,,,4190.48,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4190.48,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4190.48,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4190.48,,,percent of total billed charges,,,,,,,,,,,,,,,4190.48,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4190.48,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4190.48,,,percent of total billed charges,,,,,,1885.72,,,percent of total billed charges,,,,,,,,,,,,,,,4190.48,,,fee schedule,,,,,,,,,,,,,,,4190.48,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4190.48,,,fee schedule,,,,,,,,,,,,,,,4190.48,,,fee schedule,,,,,,,,,,,,,,,2514.29,,,percent of total billed charges,,,,,,4190.48,,,percent of total billed charges,,,,,,2514.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4190.48,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4190.48,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3561.91,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
HC LandD LUXURY ROOM,14295019,CDM,0142,RC,,,,,,inpatient,facility,,,4001.72,4001.72,295.98,7000,,3538,,,per diem,,,,,,4001.72,,,fee schedule,,,,,,3401.46,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4001.72,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4001.72,,,case rate,,,,,,4001.72,,,case rate,,,,,,4001.72,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4001.72,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2801.2,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2000.86,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2000.86,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2601.12,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4001.72,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2801.2,,,percent of total billed charges,,,,,,,,,,,,,,,4001.72,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2841.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2801.2,,,percent of total billed charges,,,,,,2401.03,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,3401.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4001.72,,,percent of total billed charges,,,,,,4001.72,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2401.03,,,percent of total billed charges,,,,,,4001.72,,,fee schedule,,,,,,4001.72,,,fee schedule,,,,,,4001.72,,,fee schedule,,,,,,4001.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4001.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3001.29,,,percent of total billed charges,,,,,,4001.72,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4001.72,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4001.72,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4001.72,,,percent of total billed charges,,,,,,,,,,,,,,,4001.72,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4001.72,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4001.72,,,percent of total billed charges,,,,,,1800.77,,,percent of total billed charges,,,,,,,,,,,,,,,4001.72,,,fee schedule,,,,,,,,,,,,,,,4001.72,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4001.72,,,fee schedule,,,,,,,,,,,,,,,4001.72,,,fee schedule,,,,,,,,,,,,,,,2401.03,,,percent of total billed charges,,,,,,4001.72,,,percent of total billed charges,,,,,,2401.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4001.72,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4001.72,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3401.46,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
ENDO MANIPULATOR UTERINE CLEARVIEW TIP 7CM  i,14389,CDM,0272,RC,,,,,,inpatient,facility,,,262.5,262.5,118.13,262.5,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.75,,,percent of total billed charges,,,,,,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,,,,,,,,,
ENDO MANIPULATOR UTERINE CLEARVIEW TIP 7CM  i,14389,CDM,0272,RC,,,,,,outpatient,facility,,,262.5,262.5,49.88,1016,,170.63,,,percent of total billed charges,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,78.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,123.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,49.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,196.88,,,percent of total billed charges,,,,,,183.75,,,percent of total billed charges,,,,,,183.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,170.63,,,percent of total billed charges,,,,,,63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",177.19,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,262.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",183.75,,,percent of total billed charges,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,183.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,186.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.75,,,percent of total billed charges,,,,,,157.5,,,percent of total billed charges,,,,,,118.13,,,percent of total billed charges,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,262.5,,,percent of total billed charges,,,,,,112.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,262.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,262.5,,,percent of total billed charges,,,,,,118.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,fee schedule,,,,,,262.5,,,percent of total billed charges,,,,,,262.5,,,percent of total billed charges,,,,,,262.5,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,154.88,,,percent of total billed charges,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,223.12,,,percent of total billed charges,,,,,,196.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LSCP INTRO CYSTIC DUCT 12F 4.0  i,14403,CDM,0272,RC,,,,,,inpatient,facility,,,399,399,179.55,399,,,,,,,,,,,,,,,,,,,,339.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.3,,,percent of total billed charges,,,,,,239.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,399,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.15,,,percent of total billed charges,,,,,,,,,,,,,,
LSCP INTRO CYSTIC DUCT 12F 4.0  i,14403,CDM,0272,RC,,,,,,outpatient,facility,,,399,399,75.81,1016,,259.35,,,percent of total billed charges,,,,,,,,,,,,,,,339.15,,,percent of total billed charges,,,,,,119.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,75.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,299.25,,,percent of total billed charges,,,,,,279.3,,,percent of total billed charges,,,,,,279.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.35,,,percent of total billed charges,,,,,,95.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",269.32,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,399,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.58,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.3,,,percent of total billed charges,,,,,,,,,,,,,,,399,,,percent of total billed charges,,,,,,278.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.3,,,percent of total billed charges,,,,,,239.4,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,,,,,,,,,,339.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399,,,percent of total billed charges,,,,,,399,,,percent of total billed charges,,,,,,171.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,399,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,399,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.25,,,percent of total billed charges,,,,,,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,399,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,399,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399,,,fee schedule,,,,,,399,,,percent of total billed charges,,,,,,399,,,percent of total billed charges,,,,,,399,,,percent of total billed charges,,,,,,191.52,,,percent of total billed charges,,,,,,,,,,,,,,,235.41,,,percent of total billed charges,,,,,,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,399,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.15,,,percent of total billed charges,,,,,,299.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD STRT 6 X 60,14438,CDM,0278,RC,,,,,,inpatient,facility,,,1182.08,1182.08,531.94,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,886.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,714.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,768.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD STRT 6 X 60,14438,CDM,0278,RC,,,,,,outpatient,facility,,,1182.08,1182.08,129.72,1182.08,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,354.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,224.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,886.56,,,percent of total billed charges,,,,,,827.46,,,percent of total billed charges,,,,,,827.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,768.35,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1182.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,650.14,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,824.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,839.28,,,percent of total billed charges,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,827.46,,,percent of total billed charges,,,,,,709.25,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.14,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1182.08,,,percent of total billed charges,,,,,,531.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,886.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1182.08,,,fee schedule,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,1182.08,,,percent of total billed charges,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,650.14,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1182.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.77,,,percent of total billed charges,,,,,,886.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STYLET MED KIT 58CM 6048,1450,CDM,0272,RC,,,,,,inpatient,facility,,,112,112,50.4,112,,,,,,,,,,,,,,,,,,,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,78.4,,,percent of total billed charges,,,,,,67.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,112,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,50.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,
STYLET MED KIT 58CM 6048,1450,CDM,0272,RC,,,,,,outpatient,facility,,,112,112,21.28,1016,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,95.2,,,percent of total billed charges,,,,,,33.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,21.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,84,,,percent of total billed charges,,,,,,78.4,,,percent of total billed charges,,,,,,78.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,26.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",75.6,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,112,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,47.04,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",78.4,,,percent of total billed charges,,,,,,,,,,,,,,,112,,,percent of total billed charges,,,,,,78.12,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,79.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,78.4,,,percent of total billed charges,,,,,,67.2,,,percent of total billed charges,,,,,,50.4,,,percent of total billed charges,,,,,,,,,,,,,,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112,,,percent of total billed charges,,,,,,112,,,percent of total billed charges,,,,,,48.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,112,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,112,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,percent of total billed charges,,,,,,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,112,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,112,,,percent of total billed charges,,,,,,50.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112,,,fee schedule,,,,,,112,,,percent of total billed charges,,,,,,112,,,percent of total billed charges,,,,,,112,,,percent of total billed charges,,,,,,53.76,,,percent of total billed charges,,,,,,,,,,,,,,,66.08,,,percent of total billed charges,,,,,,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,95.2,,,percent of total billed charges,,,,,,84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN ZIM STEINMAN THRD STRL 5 64,14548,CDM,0278,RC,,,,,,inpatient,facility,,,62.3,62.3,28.04,62.3,,,,,,,,,,,,,,,,,,,,52.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.84,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,46.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",44.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,43.61,,,percent of total billed charges,,,,,,37.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,62.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,28.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.96,,,percent of total billed charges,,,,,,40.49,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN ZIM STEINMAN THRD STRL 5 64,14548,CDM,0278,RC,,,,,,outpatient,facility,,,62.3,62.3,11.84,138.8,,40.49,,,percent of total billed charges,,,,,,,,,,,,,,,52.96,,,percent of total billed charges,,,,,,18.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,11.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,34.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,34.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.72,,,percent of total billed charges,,,,,,43.61,,,percent of total billed charges,,,,,,43.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,40.49,,,percent of total billed charges,,,,,,14.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,62.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,26.17,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",43.61,,,percent of total billed charges,,,,,,,,,,,,,,,62.3,,,percent of total billed charges,,,,,,43.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,44.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,43.61,,,percent of total billed charges,,,,,,37.38,,,percent of total billed charges,,,,,,28.04,,,percent of total billed charges,,,,,,,,,,,,,,,52.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.3,,,percent of total billed charges,,,,,,62.3,,,percent of total billed charges,,,,,,26.79,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,62.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,62.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.72,,,percent of total billed charges,,,,,,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,62.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,62.3,,,percent of total billed charges,,,,,,28.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.3,,,fee schedule,,,,,,62.3,,,percent of total billed charges,,,,,,62.3,,,percent of total billed charges,,,,,,62.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,62.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,52.96,,,percent of total billed charges,,,,,,46.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 15 NC,14629,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 15 NC,14629,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 20 NC,14630,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 20 NC,14630,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 25 NC,14631,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 25 NC,14631,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 30 NC,14632,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 30 NC,14632,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 35 NC,14633,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 35 NC,14633,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 40 NC,14634,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 40 NC,14634,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 45 NC,14635,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 45 NC,14635,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 50 NC,14636,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 50 NC,14636,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 55 NC,14637,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 55 NC,14637,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 60 NC,14638,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 60 NC,14638,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 65 NC,14639,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 65 NC,14639,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP CANC 6.5 X 70 NC,14640,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP CANC 6.5 X 70 NC,14640,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE 26   4,14669,CDM,0278,RC,,,,,,inpatient,facility,,,833,833,374.85,833,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,666.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,624.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,458.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,503.55,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",591.43,,,percent of total billed charges,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,583.1,,,percent of total billed charges,,,,,,499.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,833,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,541.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE 26   4,14669,CDM,0278,RC,,,,,,outpatient,facility,,,833,833,129.72,833,,541.45,,,percent of total billed charges,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,249.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,391.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,158.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,158.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,624.75,,,percent of total billed charges,,,,,,583.1,,,percent of total billed charges,,,,,,583.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,541.45,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,833,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,583.1,,,percent of total billed charges,,,,,,458.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,581.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,591.43,,,percent of total billed charges,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,583.1,,,percent of total billed charges,,,,,,499.8,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,708.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,,percent of total billed charges,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,833,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,458.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,833,,,fee schedule,,,,,,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,833,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,833,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,708.05,,,percent of total billed charges,,,,,,624.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PUNCH AORTIC 4.0M  i,14738,CDM,0272,RC,,,,,,inpatient,facility,,,133,133,59.85,133,,,,,,,,,,,,,,,,,,,,113.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.1,,,percent of total billed charges,,,,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.05,,,percent of total billed charges,,,,,,,,,,,,,,
PUNCH AORTIC 4.0M  i,14738,CDM,0272,RC,,,,,,outpatient,facility,,,133,133,25.27,1016,,86.45,,,percent of total billed charges,,,,,,,,,,,,,,,113.05,,,percent of total billed charges,,,,,,39.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,99.75,,,percent of total billed charges,,,,,,93.1,,,percent of total billed charges,,,,,,93.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.45,,,percent of total billed charges,,,,,,31.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",89.78,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.86,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.1,,,percent of total billed charges,,,,,,,,,,,,,,,133,,,percent of total billed charges,,,,,,92.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.1,,,percent of total billed charges,,,,,,79.8,,,percent of total billed charges,,,,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,113.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133,,,percent of total billed charges,,,,,,133,,,percent of total billed charges,,,,,,57.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.75,,,percent of total billed charges,,,,,,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133,,,percent of total billed charges,,,,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133,,,fee schedule,,,,,,133,,,percent of total billed charges,,,,,,133,,,percent of total billed charges,,,,,,133,,,percent of total billed charges,,,,,,63.84,,,percent of total billed charges,,,,,,,,,,,,,,,78.47,,,percent of total billed charges,,,,,,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.05,,,percent of total billed charges,,,,,,99.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SPHINCTEROTOME XL SN 5.5F X 200,14909,CDM,0272,RC,,,,,,inpatient,facility,,,470.15,470.15,211.57,470.15,,,,,,,,,,,,,,,,,,,,399.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,305.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,333.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,329.1,,,percent of total billed charges,,,,,,282.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,399.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,470.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,211.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.63,,,percent of total billed charges,,,,,,,,,,,,,,
SPHINCTEROTOME XL SN 5.5F X 200,14909,CDM,0272,RC,,,,,,outpatient,facility,,,470.15,470.15,89.33,1016,,305.6,,,percent of total billed charges,,,,,,,,,,,,,,,399.63,,,percent of total billed charges,,,,,,141.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,220.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,89.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,89.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,352.61,,,percent of total billed charges,,,,,,329.11,,,percent of total billed charges,,,,,,329.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,305.6,,,percent of total billed charges,,,,,,112.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",317.35,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,470.15,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,197.46,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",329.1,,,percent of total billed charges,,,,,,,,,,,,,,,470.15,,,percent of total billed charges,,,,,,327.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,333.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,329.1,,,percent of total billed charges,,,,,,282.09,,,percent of total billed charges,,,,,,211.57,,,percent of total billed charges,,,,,,,,,,,,,,,399.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.15,,,percent of total billed charges,,,,,,470.15,,,percent of total billed charges,,,,,,202.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,470.15,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,470.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.61,,,percent of total billed charges,,,,,,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,470.15,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,470.15,,,percent of total billed charges,,,,,,211.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470.15,,,fee schedule,,,,,,470.15,,,percent of total billed charges,,,,,,470.15,,,percent of total billed charges,,,,,,470.15,,,percent of total billed charges,,,,,,225.67,,,percent of total billed charges,,,,,,,,,,,,,,,277.39,,,percent of total billed charges,,,,,,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,470.15,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,399.63,,,percent of total billed charges,,,,,,352.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PORT POWERPORT ISP MRI OPEN END SNGL LMN CATH 9.6F,15067,CDM,0278,RC,,,,,,inpatient,facility,,,700,700,315,700,,,,,,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,560,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,525,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,423.15,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",497,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,490,,,percent of total billed charges,,,,,,420,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,385,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,700,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,700,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,,,,455,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PORT POWERPORT ISP MRI OPEN END SNGL LMN CATH 9.6F,15067,CDM,0278,RC,,,,,,outpatient,facility,,,700,700,129.72,700,,455,,,percent of total billed charges,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,,,,210,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,329,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,133,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,385,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,385,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,385,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,525,,,percent of total billed charges,,,,,,490,,,percent of total billed charges,,,,,,490,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,455,,,percent of total billed charges,,,,,,385,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,700,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,294,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",490,,,percent of total billed charges,,,,,,,,,,,,,,,700,,,percent of total billed charges,,,,,,488.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,497,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,490,,,percent of total billed charges,,,,,,420,,,percent of total billed charges,,,,,,315,,,percent of total billed charges,,,,,,,,,,,,,,,595,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,700,,,percent of total billed charges,,,,,,700,,,percent of total billed charges,,,,,,385,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,700,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,700,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525,,,percent of total billed charges,,,,,,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,700,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,700,,,percent of total billed charges,,,,,,315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,700,,,fee schedule,,,,,,700,,,percent of total billed charges,,,,,,700,,,percent of total billed charges,,,,,,700,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,700,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,595,,,percent of total billed charges,,,,,,525,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TRANSDUCER PRESSURE DISP 3ML HR FLUSH DEVICE VENT,15196,CDM,0272,RC,,,,,,inpatient,facility,,,50.22,50.22,22.6,50.22,,,,,,,,,,,,,,,,,,,,42.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,30.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,42.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,50.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,22.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.69,,,percent of total billed charges,,,,,,,,,,,,,,
TRANSDUCER PRESSURE DISP 3ML HR FLUSH DEVICE VENT,15196,CDM,0272,RC,,,,,,outpatient,facility,,,50.22,50.22,9.54,1016,,32.64,,,percent of total billed charges,,,,,,,,,,,,,,,42.69,,,percent of total billed charges,,,,,,15.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,23.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,9.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,9.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,37.67,,,percent of total billed charges,,,,,,35.15,,,percent of total billed charges,,,,,,35.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,32.64,,,percent of total billed charges,,,,,,12.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",33.9,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,50.22,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,21.09,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",35.15,,,percent of total billed charges,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,,,,35.03,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,35.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,30.13,,,percent of total billed charges,,,,,,22.6,,,percent of total billed charges,,,,,,,,,,,,,,,42.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,,,,50.22,,,percent of total billed charges,,,,,,21.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,50.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.66,,,percent of total billed charges,,,,,,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,50.22,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,50.22,,,percent of total billed charges,,,,,,22.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.22,,,fee schedule,,,,,,50.22,,,percent of total billed charges,,,,,,50.22,,,percent of total billed charges,,,,,,50.22,,,percent of total billed charges,,,,,,24.11,,,percent of total billed charges,,,,,,,,,,,,,,,29.63,,,percent of total billed charges,,,,,,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,50.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,42.69,,,percent of total billed charges,,,,,,37.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ENDO LIGATING CLIP SML LT100  i,1527,CDM,0272,RC,,,,,,inpatient,facility,,,55.27,55.27,24.87,55.27,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,38.69,,,percent of total billed charges,,,,,,33.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,55.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,,,,,,
ENDO LIGATING CLIP SML LT100  i,1527,CDM,0272,RC,,,,,,outpatient,facility,,,55.27,55.27,10.5,1016,,35.93,,,percent of total billed charges,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,16.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,10.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,10.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,41.46,,,percent of total billed charges,,,,,,38.69,,,percent of total billed charges,,,,,,38.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,35.93,,,percent of total billed charges,,,,,,13.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",37.31,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,55.27,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.21,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",38.69,,,percent of total billed charges,,,,,,,,,,,,,,,55.27,,,percent of total billed charges,,,,,,38.55,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,39.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,38.69,,,percent of total billed charges,,,,,,33.16,,,percent of total billed charges,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.27,,,percent of total billed charges,,,,,,55.27,,,percent of total billed charges,,,,,,23.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,55.27,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,55.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.45,,,percent of total billed charges,,,,,,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.27,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,55.27,,,percent of total billed charges,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.27,,,fee schedule,,,,,,55.27,,,percent of total billed charges,,,,,,55.27,,,percent of total billed charges,,,,,,55.27,,,percent of total billed charges,,,,,,26.53,,,percent of total billed charges,,,,,,,,,,,,,,,32.61,,,percent of total billed charges,,,,,,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,55.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.98,,,percent of total billed charges,,,,,,41.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP SS 4H 3.5 X 49,15876,CDM,0278,RC,,,,,,inpatient,facility,,,623.5,623.5,280.57,623.5,,,,,,,,,,,,,,,,,,,,529.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,467.62,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,376.91,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",442.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,436.45,,,percent of total billed charges,,,,,,374.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,529.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.93,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,342.93,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,623.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,280.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.98,,,percent of total billed charges,,,,,,405.28,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP SS 4H 3.5 X 49,15876,CDM,0278,RC,,,,,,outpatient,facility,,,623.5,623.5,118.47,623.5,,405.27,,,percent of total billed charges,,,,,,,,,,,,,,,529.98,,,percent of total billed charges,,,,,,187.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,293.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,118.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,118.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,342.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,342.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,342.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.62,,,percent of total billed charges,,,,,,436.45,,,percent of total billed charges,,,,,,436.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,405.28,,,percent of total billed charges,,,,,,342.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,623.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",436.45,,,percent of total billed charges,,,,,,,,,,,,,,,623.5,,,percent of total billed charges,,,,,,434.89,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,442.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,436.45,,,percent of total billed charges,,,,,,374.1,,,percent of total billed charges,,,,,,280.57,,,percent of total billed charges,,,,,,,,,,,,,,,529.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.93,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,623.5,,,percent of total billed charges,,,,,,623.5,,,percent of total billed charges,,,,,,342.93,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,623.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,623.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.62,,,percent of total billed charges,,,,,,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,623.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,623.5,,,percent of total billed charges,,,,,,280.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.5,,,fee schedule,,,,,,623.5,,,percent of total billed charges,,,,,,623.5,,,percent of total billed charges,,,,,,623.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,623.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,529.98,,,percent of total billed charges,,,,,,467.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP SS 5H 3.5 X 61,15877,CDM,0278,RC,,,,,,inpatient,facility,,,299.64,299.64,134.84,299.64,,,,,,,,,,,,,,,,,,,,254.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.71,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,224.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.13,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",212.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.75,,,percent of total billed charges,,,,,,179.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,254.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,299.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,134.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.69,,,percent of total billed charges,,,,,,194.77,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP SS 5H 3.5 X 61,15877,CDM,0278,RC,,,,,,outpatient,facility,,,299.64,299.64,56.93,299.64,,194.77,,,percent of total billed charges,,,,,,,,,,,,,,,254.69,,,percent of total billed charges,,,,,,89.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,140.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,56.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,56.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,164.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,164.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,224.73,,,percent of total billed charges,,,,,,209.75,,,percent of total billed charges,,,,,,209.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,194.77,,,percent of total billed charges,,,,,,71.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,299.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,125.85,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",209.75,,,percent of total billed charges,,,,,,,,,,,,,,,299.64,,,percent of total billed charges,,,,,,209,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,212.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.75,,,percent of total billed charges,,,,,,179.78,,,percent of total billed charges,,,,,,134.84,,,percent of total billed charges,,,,,,,,,,,,,,,254.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.64,,,percent of total billed charges,,,,,,299.64,,,percent of total billed charges,,,,,,128.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,299.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,299.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.73,,,percent of total billed charges,,,,,,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,299.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,299.64,,,percent of total billed charges,,,,,,134.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.64,,,fee schedule,,,,,,299.64,,,percent of total billed charges,,,,,,299.64,,,percent of total billed charges,,,,,,299.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,299.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,254.69,,,percent of total billed charges,,,,,,224.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC ISOLATION,16490004,CDM,0164,RC,,,,,,inpatient,facility,,,3081.65,3081.65,295.98,7000,,3538,,,per diem,,,,,,3081.65,,,fee schedule,,,,,,2619.4,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3081.65,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,3081.65,,,case rate,,,,,,3081.65,,,case rate,,,,,,3081.65,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,3081.65,,,case rate,,,,,,1960,,,per diem,,,,,,1310,,,per diem,,,,,,2157.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1540.83,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1540.83,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2003.07,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,3081.65,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,2157.15,,,percent of total billed charges,,,,,,,,,,,,,,,3081.65,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2187.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2157.16,,,percent of total billed charges,,,,,,1848.99,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,2619.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3081.65,,,percent of total billed charges,,,,,,3081.65,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848.99,,,percent of total billed charges,,,,,,3081.65,,,fee schedule,,,,,,3081.65,,,fee schedule,,,,,,3081.65,,,fee schedule,,,,,,3081.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,3081.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2311.24,,,percent of total billed charges,,,,,,3081.65,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3081.65,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3081.65,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3081.65,,,percent of total billed charges,,,,,,,,,,,,,,,3081.65,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3081.65,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3081.65,,,percent of total billed charges,,,,,,1386.74,,,percent of total billed charges,,,,,,,,,,,,,,,3081.65,,,fee schedule,,,,,,,,,,,,,,,3081.65,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,3081.65,,,fee schedule,,,,,,,,,,,,,,,3081.65,,,fee schedule,,,,,,,,,,,,,,,1848.99,,,percent of total billed charges,,,,,,3081.65,,,percent of total billed charges,,,,,,1848.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3081.65,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3081.65,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,2619.4,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
SCR SYN CANN MINI TI SHRT TH 4.0 X 10,16575,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 10,16575,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 12,16576,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 12,16576,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 14,16577,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 14,16577,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 16,16578,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 16,16578,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 18,16579,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 18,16579,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 20,16580,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 20,16580,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 22,16581,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 22,16581,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 24,16582,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 24,16582,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 26,16583,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 26,16583,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 28,16584,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 28,16584,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 30,16585,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 30,16585,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 32,16586,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 32,16586,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 34,16587,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 34,16587,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 36,16588,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 36,16588,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 38,16589,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 38,16589,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 40,16590,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 40,16590,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 44,16591,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 44,16591,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 46,16592,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 46,16592,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 48,16593,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 48,16593,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 50,16594,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 50,16594,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ENDOTRACH CUFF MUR 5.5,16796,CDM,0272,RC,,,,,,inpatient,facility,,,5.89,5.89,2.65,5.89,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,3.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ENDOTRACH CUFF MUR 5.5,16796,CDM,0272,RC,,,,,,outpatient,facility,,,5.89,5.89,1.12,1016,,3.83,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,1.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.42,,,percent of total billed charges,,,,,,4.12,,,percent of total billed charges,,,,,,4.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.83,,,percent of total billed charges,,,,,,1.41,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.98,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.89,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.47,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.12,,,percent of total billed charges,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,4.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,4.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,3.53,,,percent of total billed charges,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,5.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,5.89,,,percent of total billed charges,,,,,,2.53,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.89,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.89,,,percent of total billed charges,,,,,,2.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.89,,,fee schedule,,,,,,5.89,,,percent of total billed charges,,,,,,5.89,,,percent of total billed charges,,,,,,5.89,,,percent of total billed charges,,,,,,2.83,,,percent of total billed charges,,,,,,,,,,,,,,,3.48,,,percent of total billed charges,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.01,,,percent of total billed charges,,,,,,4.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ORAL RAE W CUFF 7.0,16799,CDM,0272,RC,,,,,,inpatient,facility,,,16.65,16.65,7.49,16.65,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,9.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ORAL RAE W CUFF 7.0,16799,CDM,0272,RC,,,,,,outpatient,facility,,,16.65,16.65,3.16,1016,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,4.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,12.49,,,percent of total billed charges,,,,,,11.65,,,percent of total billed charges,,,,,,11.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.24,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.65,,,percent of total billed charges,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,11.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,11.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,9.99,,,percent of total billed charges,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,7.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,,percent of total billed charges,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,fee schedule,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,7.99,,,percent of total billed charges,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.15,,,percent of total billed charges,,,,,,12.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ORAL RAE W CUFF 6.0,16801,CDM,0272,RC,,,,,,inpatient,facility,,,16.65,16.65,7.49,16.65,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,9.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ORAL RAE W CUFF 6.0,16801,CDM,0272,RC,,,,,,outpatient,facility,,,16.65,16.65,3.16,1016,,10.82,,,percent of total billed charges,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,4.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,12.49,,,percent of total billed charges,,,,,,11.65,,,percent of total billed charges,,,,,,11.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,10.82,,,percent of total billed charges,,,,,,4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.24,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.65,,,percent of total billed charges,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,11.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,11.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.66,,,percent of total billed charges,,,,,,9.99,,,percent of total billed charges,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,14.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,7.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.65,,,percent of total billed charges,,,,,,7.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.65,,,fee schedule,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,16.65,,,percent of total billed charges,,,,,,7.99,,,percent of total billed charges,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.15,,,percent of total billed charges,,,,,,12.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE NASAL RAE W CUFF 6.0,16806,CDM,0272,RC,,,,,,inpatient,facility,,,16.57,16.57,7.46,16.57,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE NASAL RAE W CUFF 6.0,16806,CDM,0272,RC,,,,,,outpatient,facility,,,16.57,16.57,3.15,1016,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,4.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,12.42,,,percent of total billed charges,,,,,,11.6,,,percent of total billed charges,,,,,,11.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,3.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.18,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.96,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,11.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,fee schedule,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.08,,,percent of total billed charges,,,,,,12.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE NASAL RAE W CUFF 6.5,16807,CDM,0272,RC,,,,,,inpatient,facility,,,16.57,16.57,7.46,16.57,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE NASAL RAE W CUFF 6.5,16807,CDM,0272,RC,,,,,,outpatient,facility,,,16.57,16.57,3.15,1016,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,4.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,12.42,,,percent of total billed charges,,,,,,11.6,,,percent of total billed charges,,,,,,11.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,3.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.18,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.96,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,11.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,fee schedule,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.08,,,percent of total billed charges,,,,,,12.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE NASAL RAE W CUFF 8.0,16808,CDM,0272,RC,,,,,,inpatient,facility,,,16.57,16.57,7.46,16.57,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE NASAL RAE W CUFF 8.0,16808,CDM,0272,RC,,,,,,outpatient,facility,,,16.57,16.57,3.15,1016,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,4.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,12.42,,,percent of total billed charges,,,,,,11.6,,,percent of total billed charges,,,,,,11.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,3.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.18,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.96,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,11.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,fee schedule,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.08,,,percent of total billed charges,,,,,,12.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE NASAL RAE W CUFF 7.5,16809,CDM,0272,RC,,,,,,inpatient,facility,,,16.57,16.57,7.46,16.57,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE NASAL RAE W CUFF 7.5,16809,CDM,0272,RC,,,,,,outpatient,facility,,,16.57,16.57,3.15,1016,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,4.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,12.42,,,percent of total billed charges,,,,,,11.6,,,percent of total billed charges,,,,,,11.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,3.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.18,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.96,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,11.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,fee schedule,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.08,,,percent of total billed charges,,,,,,12.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE NASAL RAE W CUFF 7.0,16810,CDM,0272,RC,,,,,,inpatient,facility,,,16.57,16.57,7.46,16.57,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE NASAL RAE W CUFF 7.0,16810,CDM,0272,RC,,,,,,outpatient,facility,,,16.57,16.57,3.15,1016,,10.77,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,4.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,12.42,,,percent of total billed charges,,,,,,11.6,,,percent of total billed charges,,,,,,11.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,10.77,,,percent of total billed charges,,,,,,3.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.18,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.96,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",11.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,11.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,11.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.6,,,percent of total billed charges,,,,,,9.94,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,14.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,16.57,,,percent of total billed charges,,,,,,7.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.57,,,fee schedule,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,16.57,,,percent of total billed charges,,,,,,7.95,,,percent of total billed charges,,,,,,,,,,,,,,,9.78,,,percent of total billed charges,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,16.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.08,,,percent of total billed charges,,,,,,12.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SET CATH VENT HERMETIC DRAIN STD 35CM  i,1686,CDM,0272,RC,,,,,,inpatient,facility,,,473.86,473.86,213.24,473.86,,,,,,,,,,,,,,,,,,,,402.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,331.7,,,percent of total billed charges,,,,,,284.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,402.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,473.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,213.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.78,,,percent of total billed charges,,,,,,,,,,,,,,
SET CATH VENT HERMETIC DRAIN STD 35CM  i,1686,CDM,0272,RC,,,,,,outpatient,facility,,,473.86,473.86,90.03,1016,,308.01,,,percent of total billed charges,,,,,,,,,,,,,,,402.78,,,percent of total billed charges,,,,,,142.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,222.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,90.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,355.4,,,percent of total billed charges,,,,,,331.7,,,percent of total billed charges,,,,,,331.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,308.01,,,percent of total billed charges,,,,,,113.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",319.86,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,473.86,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,199.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",331.7,,,percent of total billed charges,,,,,,,,,,,,,,,473.86,,,percent of total billed charges,,,,,,330.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,336.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,331.7,,,percent of total billed charges,,,,,,284.32,,,percent of total billed charges,,,,,,213.24,,,percent of total billed charges,,,,,,,,,,,,,,,402.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.86,,,percent of total billed charges,,,,,,473.86,,,percent of total billed charges,,,,,,203.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,473.86,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,473.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.4,,,percent of total billed charges,,,,,,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,473.86,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,473.86,,,percent of total billed charges,,,,,,213.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,473.86,,,fee schedule,,,,,,473.86,,,percent of total billed charges,,,,,,473.86,,,percent of total billed charges,,,,,,473.86,,,percent of total billed charges,,,,,,227.45,,,percent of total billed charges,,,,,,,,,,,,,,,279.58,,,percent of total billed charges,,,,,,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,473.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,402.78,,,percent of total billed charges,,,,,,355.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHUNT CONNECTOR PS 3WY MED  i,1690,CDM,0278,RC,,,,,,inpatient,facility,,,436,436,196.2,436,,,,,,,,,,,,,,,,,,,,370.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,327,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",309.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,305.2,,,percent of total billed charges,,,,,,261.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,370.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,436,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,196.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.6,,,percent of total billed charges,,,,,,283.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHUNT CONNECTOR PS 3WY MED  i,1690,CDM,0278,RC,,,,,,outpatient,facility,,,436,436,82.84,436,,283.4,,,percent of total billed charges,,,,,,,,,,,,,,,370.6,,,percent of total billed charges,,,,,,130.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,204.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,82.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,82.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,239.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,239.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,239.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,327,,,percent of total billed charges,,,,,,305.2,,,percent of total billed charges,,,,,,305.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,283.4,,,percent of total billed charges,,,,,,104.64,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,436,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,183.12,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",305.2,,,percent of total billed charges,,,,,,,,,,,,,,,436,,,percent of total billed charges,,,,,,304.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,309.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,305.2,,,percent of total billed charges,,,,,,261.6,,,percent of total billed charges,,,,,,196.2,,,percent of total billed charges,,,,,,,,,,,,,,,370.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436,,,percent of total billed charges,,,,,,436,,,percent of total billed charges,,,,,,187.48,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,436,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,436,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327,,,percent of total billed charges,,,,,,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,436,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,436,,,percent of total billed charges,,,,,,196.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436,,,fee schedule,,,,,,436,,,percent of total billed charges,,,,,,436,,,percent of total billed charges,,,,,,436,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,436,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,370.6,,,percent of total billed charges,,,,,,327,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHUNT RESERVOIR OMAYA 2.5INLET  i,1691,CDM,0278,RC,,,,,,inpatient,facility,,,1514,1514,681.3,1514,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1286.9,,,percent of total billed charges,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1135.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.7,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,915.21,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1074.94,,,percent of total billed charges,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1059.8,,,percent of total billed charges,,,,,,908.4,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1286.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1514,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1135.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1514,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,681.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1286.9,,,percent of total billed charges,,,,,,984.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHUNT RESERVOIR OMAYA 2.5INLET  i,1691,CDM,0278,RC,,,,,,outpatient,facility,,,1514,1514,129.72,1514,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1286.9,,,percent of total billed charges,,,,,,454.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,287.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,287.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1135.5,,,percent of total billed charges,,,,,,1059.8,,,percent of total billed charges,,,,,,1059.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,984.1,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1514,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.8,,,percent of total billed charges,,,,,,832.7,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,,percent of total billed charges,,,,,,1056.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1074.94,,,percent of total billed charges,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.8,,,percent of total billed charges,,,,,,908.4,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1286.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,,percent of total billed charges,,,,,,1514,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1514,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1135.5,,,percent of total billed charges,,,,,,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1514,,,percent of total billed charges,,,,,,681.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1135.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1514,,,fee schedule,,,,,,1514,,,percent of total billed charges,,,,,,1514,,,percent of total billed charges,,,,,,1514,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1286.9,,,percent of total billed charges,,,,,,1135.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHUNT RESERVIOR OMAYA 1.5 VCTH  i,1693,CDM,0278,RC,,,,,,inpatient,facility,,,1514,1514,681.3,1514,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1286.9,,,percent of total billed charges,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1211.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1135.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.7,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,915.21,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1074.94,,,percent of total billed charges,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1059.8,,,percent of total billed charges,,,,,,908.4,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1286.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1514,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1135.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1514,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,681.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1286.9,,,percent of total billed charges,,,,,,984.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHUNT RESERVIOR OMAYA 1.5 VCTH  i,1693,CDM,0278,RC,,,,,,outpatient,facility,,,1514,1514,129.72,1514,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1286.9,,,percent of total billed charges,,,,,,454.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,287.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,287.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1135.5,,,percent of total billed charges,,,,,,1059.8,,,percent of total billed charges,,,,,,1059.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,984.1,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1514,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.8,,,percent of total billed charges,,,,,,832.7,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,,percent of total billed charges,,,,,,1056.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1074.94,,,percent of total billed charges,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.8,,,percent of total billed charges,,,,,,908.4,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1286.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.7,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,,percent of total billed charges,,,,,,1514,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1514,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1135.5,,,percent of total billed charges,,,,,,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1514,,,percent of total billed charges,,,,,,681.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1135.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1514,,,fee schedule,,,,,,1514,,,percent of total billed charges,,,,,,1514,,,percent of total billed charges,,,,,,1514,,,percent of total billed charges,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,832.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1514,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1286.9,,,percent of total billed charges,,,,,,1135.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SPECIAL CARE,16996980,CDM,0169,RC,,,,,,inpatient,facility,,,4876.3,4876.3,295.98,7000,,3408,,,per diem,,,,,,4876.3,,,fee schedule,,,,,,4144.86,,,percent of total billed charges,,,,,,,,,,,,,,,2571,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.3,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4876.3,,,case rate,,,,,,4876.3,,,case rate,,,,,,4876.3,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4876.3,,,case rate,,,,,,1960,,,per diem,,,,,,3657.23,,,percent of total billed charges,,,,,,3413.41,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2438.15,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2438.15,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3169.6,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4876.3,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,3413.41,,,percent of total billed charges,,,,,,,,,,,,,,,4876.3,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3462.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3413.41,,,percent of total billed charges,,,,,,2925.78,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,4144.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4876.3,,,percent of total billed charges,,,,,,4876.3,,,percent of total billed charges,,,,,,1816,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2925.78,,,percent of total billed charges,,,,,,4876.3,,,fee schedule,,,,,,4876.3,,,fee schedule,,,,,,4876.3,,,fee schedule,,,,,,4876.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4876.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3657.23,,,percent of total billed charges,,,,,,4876.3,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4876.3,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4876.3,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4876.3,,,percent of total billed charges,,,,,,,,,,,,,,,4876.3,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4876.3,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4876.3,,,percent of total billed charges,,,,,,2194.34,,,percent of total billed charges,,,,,,,,,,,,,,,4876.3,,,fee schedule,,,,,,,,,,,,,,,4876.3,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4876.3,,,fee schedule,,,,,,,,,,,,,,,4876.3,,,fee schedule,,,,,,,,,,,,,,,2925.78,,,percent of total billed charges,,,,,,4876.3,,,percent of total billed charges,,,,,,2925.78,,,percent of total billed charges,,,,,,3747,,,per diem,,,,,,,,,,,,,,,6669,,,per diem,,,,,,4876.3,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4876.3,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,4144.86,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
SHUNT CONNECTOR PUDENZ ST  i,1700,CDM,0278,RC,,,,,,inpatient,facility,,,136.82,136.82,61.57,136.82,,,,,,,,,,,,,,,,,,,,116.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,102.61,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.71,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",97.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,95.77,,,percent of total billed charges,,,,,,82.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,61.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.3,,,percent of total billed charges,,,,,,88.93,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHUNT CONNECTOR PUDENZ ST  i,1700,CDM,0278,RC,,,,,,outpatient,facility,,,136.82,136.82,26,138.8,,88.93,,,percent of total billed charges,,,,,,,,,,,,,,,116.3,,,percent of total billed charges,,,,,,41.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,64.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,75.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,102.61,,,percent of total billed charges,,,,,,95.77,,,percent of total billed charges,,,,,,95.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,88.93,,,percent of total billed charges,,,,,,32.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,136.82,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",95.77,,,percent of total billed charges,,,,,,,,,,,,,,,136.82,,,percent of total billed charges,,,,,,95.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,97.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,95.77,,,percent of total billed charges,,,,,,82.09,,,percent of total billed charges,,,,,,61.57,,,percent of total billed charges,,,,,,,,,,,,,,,116.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.82,,,percent of total billed charges,,,,,,136.82,,,percent of total billed charges,,,,,,58.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,136.82,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,136.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.62,,,percent of total billed charges,,,,,,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,136.82,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,136.82,,,percent of total billed charges,,,,,,61.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.82,,,fee schedule,,,,,,136.82,,,percent of total billed charges,,,,,,136.82,,,percent of total billed charges,,,,,,136.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,136.82,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.3,,,percent of total billed charges,,,,,,102.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHUNT CONNECTOR ACCU FLO SS RT ANGL  i,1701,CDM,0278,RC,,,,,,inpatient,facility,,,257.74,257.74,115.98,257.74,,,,,,,,,,,,,,,,,,,,219.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,193.31,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",183,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.42,,,percent of total billed charges,,,,,,154.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,219.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,257.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.08,,,percent of total billed charges,,,,,,167.53,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHUNT CONNECTOR ACCU FLO SS RT ANGL  i,1701,CDM,0278,RC,,,,,,outpatient,facility,,,257.74,257.74,48.97,257.74,,167.53,,,percent of total billed charges,,,,,,,,,,,,,,,219.08,,,percent of total billed charges,,,,,,77.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,121.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.3,,,percent of total billed charges,,,,,,180.42,,,percent of total billed charges,,,,,,180.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,167.53,,,percent of total billed charges,,,,,,61.86,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,257.74,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",180.42,,,percent of total billed charges,,,,,,,,,,,,,,,257.74,,,percent of total billed charges,,,,,,179.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,183,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.42,,,percent of total billed charges,,,,,,154.64,,,percent of total billed charges,,,,,,115.98,,,percent of total billed charges,,,,,,,,,,,,,,,219.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.74,,,percent of total billed charges,,,,,,257.74,,,percent of total billed charges,,,,,,110.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,257.74,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,257.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.3,,,percent of total billed charges,,,,,,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.74,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.74,,,percent of total billed charges,,,,,,115.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.74,,,fee schedule,,,,,,257.74,,,percent of total billed charges,,,,,,257.74,,,percent of total billed charges,,,,,,257.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,257.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.08,,,percent of total billed charges,,,,,,193.31,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHUNT CATH CARD PERIT 90CM  i,1705,CDM,0278,RC,,,,,,inpatient,facility,,,314.94,314.94,141.72,314.94,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.95,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,236.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.38,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",223.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,220.46,,,percent of total billed charges,,,,,,188.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,314.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,141.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,204.71,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHUNT CATH CARD PERIT 90CM  i,1705,CDM,0278,RC,,,,,,outpatient,facility,,,314.94,314.94,59.84,314.94,,204.71,,,percent of total billed charges,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,94.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,148.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,59.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,173.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,173.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,173.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,236.2,,,percent of total billed charges,,,,,,220.46,,,percent of total billed charges,,,,,,220.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,204.71,,,percent of total billed charges,,,,,,75.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,314.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",220.46,,,percent of total billed charges,,,,,,,,,,,,,,,314.94,,,percent of total billed charges,,,,,,219.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,223.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,220.46,,,percent of total billed charges,,,,,,188.96,,,percent of total billed charges,,,,,,141.72,,,percent of total billed charges,,,,,,,,,,,,,,,267.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.94,,,percent of total billed charges,,,,,,314.94,,,percent of total billed charges,,,,,,135.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,314.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,314.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.2,,,percent of total billed charges,,,,,,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,314.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,314.94,,,percent of total billed charges,,,,,,141.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.94,,,fee schedule,,,,,,314.94,,,percent of total billed charges,,,,,,314.94,,,percent of total billed charges,,,,,,314.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,314.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,267.7,,,percent of total billed charges,,,,,,236.21,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHUNT CATH PERITONEAL HOLTER  i,1710,CDM,0278,RC,,,,,,inpatient,facility,,,509.12,509.12,229.1,509.12,,,,,,,,,,,,,,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,381.84,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,307.76,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",361.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,356.38,,,percent of total billed charges,,,,,,305.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.02,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,280.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,509.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,381.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,509.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,229.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.75,,,percent of total billed charges,,,,,,330.93,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHUNT CATH PERITONEAL HOLTER  i,1710,CDM,0278,RC,,,,,,outpatient,facility,,,509.12,509.12,96.73,509.12,,330.93,,,percent of total billed charges,,,,,,,,,,,,,,,432.75,,,percent of total billed charges,,,,,,152.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,239.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,96.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,96.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,280.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,280.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,280.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,381.84,,,percent of total billed charges,,,,,,356.38,,,percent of total billed charges,,,,,,356.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,330.93,,,percent of total billed charges,,,,,,280.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,509.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,213.83,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",356.38,,,percent of total billed charges,,,,,,,,,,,,,,,509.12,,,percent of total billed charges,,,,,,355.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,361.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,356.38,,,percent of total billed charges,,,,,,305.47,,,percent of total billed charges,,,,,,229.1,,,percent of total billed charges,,,,,,,,,,,,,,,432.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.02,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,509.12,,,percent of total billed charges,,,,,,509.12,,,percent of total billed charges,,,,,,280.02,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,509.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,509.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,381.84,,,percent of total billed charges,,,,,,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,509.12,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,509.12,,,percent of total billed charges,,,,,,229.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,381.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,509.12,,,fee schedule,,,,,,509.12,,,percent of total billed charges,,,,,,509.12,,,percent of total billed charges,,,,,,509.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,509.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,432.75,,,percent of total billed charges,,,,,,381.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC NSY LEVEL I,17190015,CDM,0171,RC,,,,,,inpatient,facility,,,1915.92,1915.92,295.98,7000,,1124,,,per diem,,,,,,1915.92,,,fee schedule,,,,,,1628.53,,,percent of total billed charges,,,,,,,,,,,,,,,658,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,4867.23,2508.9,7399.37,37,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1915.92,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,1915.92,,,case rate,,,,,,1915.92,,,case rate,,,,,,1915.92,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1915.92,,,case rate,,,,,,1960,,,per diem,,,,,,1750,,,per diem,,,,,,1341.14,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,957.96,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,957.96,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,1245.35,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,1915.92,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,1341.14,,,percent of total billed charges,,,,,,,,,,,,,,,1915.92,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",1360.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1341.14,,,percent of total billed charges,,,,,,1149.55,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,1628.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1915.92,,,percent of total billed charges,,,,,,1915.92,,,percent of total billed charges,,,,,,520,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1149.55,,,percent of total billed charges,,,,,,1915.92,,,fee schedule,,,,,,1915.92,,,fee schedule,,,,,,1915.92,,,fee schedule,,,,,,1915.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,1915.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1436.94,,,percent of total billed charges,,,,,,1915.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1915.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1915.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1915.92,,,percent of total billed charges,,,,,,,,,,,,,,,1915.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1915.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1915.92,,,percent of total billed charges,,,,,,862.16,,,percent of total billed charges,,,,,,,,,,,,,,,1915.92,,,fee schedule,,,,,,,,,,,,,,,1915.92,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,1915.92,,,fee schedule,,,,,,,,,,,,,,,1915.92,,,fee schedule,,,,,,,,,,,,,,,1149.55,,,percent of total billed charges,,,,,,1915.92,,,percent of total billed charges,,,,,,1149.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1915.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1915.92,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,1628.53,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
DRSG TEGADERM TRANSP 2 3 8 X 2 3 4  i,172,CDM,0272,RC,,,,,,inpatient,facility,,,0.69,0.69,0.31,0.69,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,0.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,
DRSG TEGADERM TRANSP 2 3 8 X 2 3 4  i,172,CDM,0272,RC,,,,,,outpatient,facility,,,0.69,0.69,0.13,1016,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,0.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,0.52,,,percent of total billed charges,,,,,,0.48,,,percent of total billed charges,,,,,,0.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,0.17,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.47,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,0.69,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.48,,,percent of total billed charges,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,0.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.48,,,percent of total billed charges,,,,,,0.41,,,percent of total billed charges,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,0.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,0.69,,,percent of total billed charges,,,,,,0.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,0.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.69,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,0.69,,,percent of total billed charges,,,,,,0.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.69,,,fee schedule,,,,,,0.69,,,percent of total billed charges,,,,,,0.69,,,percent of total billed charges,,,,,,0.69,,,percent of total billed charges,,,,,,0.33,,,percent of total billed charges,,,,,,,,,,,,,,,0.41,,,percent of total billed charges,,,,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,0.69,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.59,,,percent of total billed charges,,,,,,0.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC NSY LEVEL II,17290016,CDM,0172,RC,,,,,,inpatient,facility,,,5238.09,5238.09,295.98,7000,,3290,,,per diem,,,,,,5238.09,,,fee schedule,,,,,,4452.38,,,percent of total billed charges,,,,,,,,,,,,,,,1925,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,54490.07,8998.83,103689.73,1 through 10,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5238.09,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,5238.09,,,case rate,,,,,,5238.09,,,case rate,,,,,,5238.09,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,5238.09,,,case rate,,,,,,1960,,,per diem,,,,,,1750,,,per diem,,,,,,3666.66,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2619.05,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2619.05,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3404.76,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,5238.09,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,3666.66,,,percent of total billed charges,,,,,,,,,,,,,,,5238.09,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3719.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3666.66,,,percent of total billed charges,,,,,,3142.85,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,4452.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5238.09,,,percent of total billed charges,,,,,,5238.09,,,percent of total billed charges,,,,,,1930,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3142.85,,,percent of total billed charges,,,,,,5238.09,,,fee schedule,,,,,,5238.09,,,fee schedule,,,,,,5238.09,,,fee schedule,,,,,,5238.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,5238.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3928.57,,,percent of total billed charges,,,,,,5238.09,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5238.09,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5238.09,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5238.09,,,percent of total billed charges,,,,,,,,,,,,,,,5238.09,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5238.09,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5238.09,,,percent of total billed charges,,,,,,2357.14,,,percent of total billed charges,,,,,,,,,,,,,,,5238.09,,,fee schedule,,,,,,,,,,,,,,,5238.09,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,5238.09,,,fee schedule,,,,,,,,,,,,,,,5238.09,,,fee schedule,,,,,,,,,,,,,,,3142.85,,,percent of total billed charges,,,,,,5238.09,,,percent of total billed charges,,,,,,3142.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5238.09,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5238.09,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,4452.38,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
KIT CRANIOPLASTIC REPAIR  i,1739,CDM,0278,RC,,,,,,inpatient,facility,,,3931.44,3931.44,1769.15,3931.44,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,3341.72,,,percent of total billed charges,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3145.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2948.58,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2162.29,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2376.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2791.32,,,percent of total billed charges,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2752.01,,,percent of total billed charges,,,,,,2358.86,,,percent of total billed charges,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3341.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.29,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.44,,,percent of total billed charges,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2948.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3931.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1769.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3341.72,,,percent of total billed charges,,,,,,2555.44,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
KIT CRANIOPLASTIC REPAIR  i,1739,CDM,0278,RC,,,,,,outpatient,facility,,,3931.44,3931.44,129.72,3931.44,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3341.72,,,percent of total billed charges,,,,,,1179.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,746.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,746.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2948.58,,,percent of total billed charges,,,,,,2752.01,,,percent of total billed charges,,,,,,2752.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2555.44,,,percent of total billed charges,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3931.44,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2752.01,,,percent of total billed charges,,,,,,2162.29,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3931.44,,,percent of total billed charges,,,,,,2742.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2791.32,,,percent of total billed charges,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2752.01,,,percent of total billed charges,,,,,,2358.86,,,percent of total billed charges,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3341.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.29,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3931.44,,,percent of total billed charges,,,,,,3931.44,,,percent of total billed charges,,,,,,2162.29,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.44,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3931.44,,,percent of total billed charges,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2948.58,,,percent of total billed charges,,,,,,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3931.44,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3931.44,,,percent of total billed charges,,,,,,1769.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2948.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3931.44,,,fee schedule,,,,,,3931.44,,,percent of total billed charges,,,,,,3931.44,,,percent of total billed charges,,,,,,3931.44,,,percent of total billed charges,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2162.29,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3931.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3341.72,,,percent of total billed charges,,,,,,2948.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC NSY LEVEL III,17390017,CDM,0173,RC,,,,,,inpatient,facility,,,6795.36,6795.36,295.98,7000,,3919,,,per diem,,,,,,6795.36,,,fee schedule,,,,,,5776.06,,,percent of total billed charges,,,,,,,,,,,,,,,2398,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,135704.44,135704.44,135704.44,1 through 10,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6795.36,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,6795.36,,,case rate,,,,,,6795.36,,,case rate,,,,,,6795.36,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,6795.36,,,case rate,,,,,,1960,,,per diem,,,,,,1750,,,per diem,,,,,,4756.75,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3397.68,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3397.68,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,4416.98,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,6795.36,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,4756.75,,,percent of total billed charges,,,,,,,,,,,,,,,6795.36,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",4824.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4756.75,,,percent of total billed charges,,,,,,4077.22,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,5776.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6795.36,,,percent of total billed charges,,,,,,6795.36,,,percent of total billed charges,,,,,,1930,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4077.22,,,percent of total billed charges,,,,,,6795.36,,,fee schedule,,,,,,6795.36,,,fee schedule,,,,,,6795.36,,,fee schedule,,,,,,6795.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,6795.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5096.52,,,percent of total billed charges,,,,,,6795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,6795.36,,,percent of total billed charges,,,,,,,,,,,,,,,6795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6795.36,,,percent of total billed charges,,,,,,3057.91,,,percent of total billed charges,,,,,,,,,,,,,,,6795.36,,,fee schedule,,,,,,,,,,,,,,,6795.36,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,6795.36,,,fee schedule,,,,,,,,,,,,,,,6795.36,,,fee schedule,,,,,,,,,,,,,,,4077.22,,,percent of total billed charges,,,,,,6795.36,,,percent of total billed charges,,,,,,4077.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,5776.06,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
MESH MARLEX 2 X 12  i,175,CDM,0278,RC,,,,,,inpatient,facility,,,89,89,40.05,89,,,,,,,,,,,,,,,,,,,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,66.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",63.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,62.3,,,percent of total billed charges,,,,,,53.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.65,,,percent of total billed charges,,,,,,57.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
MESH MARLEX 2 X 12  i,175,CDM,0278,RC,,,,,,outpatient,facility,,,89,89,16.91,138.8,,57.85,,,percent of total billed charges,,,,,,,,,,,,,,,75.65,,,percent of total billed charges,,,,,,26.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.75,,,percent of total billed charges,,,,,,62.3,,,percent of total billed charges,,,,,,62.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.85,,,percent of total billed charges,,,,,,21.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,89,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",62.3,,,percent of total billed charges,,,,,,,,,,,,,,,89,,,percent of total billed charges,,,,,,62.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,63.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,62.3,,,percent of total billed charges,,,,,,53.4,,,percent of total billed charges,,,,,,40.05,,,percent of total billed charges,,,,,,,,,,,,,,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89,,,percent of total billed charges,,,,,,89,,,percent of total billed charges,,,,,,38.27,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,89,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.75,,,percent of total billed charges,,,,,,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,89,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,89,,,percent of total billed charges,,,,,,40.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89,,,fee schedule,,,,,,89,,,percent of total billed charges,,,,,,89,,,percent of total billed charges,,,,,,89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,75.65,,,percent of total billed charges,,,,,,66.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE GLIDE ANGL .025 X 150  i,17524,CDM,0272,RC,,,,,,inpatient,facility,,,140.02,140.02,63.01,140.02,,,,,,,,,,,,,,,,,,,,119.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98.01,,,percent of total billed charges,,,,,,84.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,140.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,63.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.02,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE GLIDE ANGL .025 X 150  i,17524,CDM,0272,RC,,,,,,outpatient,facility,,,140.02,140.02,26.6,1016,,91.01,,,percent of total billed charges,,,,,,,,,,,,,,,119.02,,,percent of total billed charges,,,,,,42.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,65.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,26.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,105.01,,,percent of total billed charges,,,,,,98.01,,,percent of total billed charges,,,,,,98.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,91.01,,,percent of total billed charges,,,,,,33.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",94.51,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,140.02,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.81,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",98.01,,,percent of total billed charges,,,,,,,,,,,,,,,140.02,,,percent of total billed charges,,,,,,97.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,99.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98.01,,,percent of total billed charges,,,,,,84.01,,,percent of total billed charges,,,,,,63.01,,,percent of total billed charges,,,,,,,,,,,,,,,119.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.02,,,percent of total billed charges,,,,,,140.02,,,percent of total billed charges,,,,,,60.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,140.02,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,140.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.02,,,percent of total billed charges,,,,,,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,140.02,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140.02,,,percent of total billed charges,,,,,,63.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.02,,,fee schedule,,,,,,140.02,,,percent of total billed charges,,,,,,140.02,,,percent of total billed charges,,,,,,140.02,,,percent of total billed charges,,,,,,67.21,,,percent of total billed charges,,,,,,,,,,,,,,,82.61,,,percent of total billed charges,,,,,,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,140.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,119.02,,,percent of total billed charges,,,,,,105.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN SKULL MAYFIELD DISP ADULT  i,1766,CDM,0272,RC,,,,,,inpatient,facility,,,169.74,169.74,76.38,169.74,,,,,,,,,,,,,,,,,,,,144.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.82,,,percent of total billed charges,,,,,,101.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,144.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,169.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.28,,,percent of total billed charges,,,,,,,,,,,,,,
PIN SKULL MAYFIELD DISP ADULT  i,1766,CDM,0272,RC,,,,,,outpatient,facility,,,169.74,169.74,32.25,1016,,110.33,,,percent of total billed charges,,,,,,,,,,,,,,,144.28,,,percent of total billed charges,,,,,,50.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,32.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,127.3,,,percent of total billed charges,,,,,,118.82,,,percent of total billed charges,,,,,,118.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,110.33,,,percent of total billed charges,,,,,,40.74,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",114.57,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,169.74,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,71.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.82,,,percent of total billed charges,,,,,,,,,,,,,,,169.74,,,percent of total billed charges,,,,,,118.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,120.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.82,,,percent of total billed charges,,,,,,101.84,,,percent of total billed charges,,,,,,76.38,,,percent of total billed charges,,,,,,,,,,,,,,,144.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.74,,,percent of total billed charges,,,,,,169.74,,,percent of total billed charges,,,,,,72.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,169.74,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,169.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.3,,,percent of total billed charges,,,,,,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,169.74,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169.74,,,percent of total billed charges,,,,,,76.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.74,,,fee schedule,,,,,,169.74,,,percent of total billed charges,,,,,,169.74,,,percent of total billed charges,,,,,,169.74,,,percent of total billed charges,,,,,,81.48,,,percent of total billed charges,,,,,,,,,,,,,,,100.15,,,percent of total billed charges,,,,,,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,169.74,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,144.28,,,percent of total billed charges,,,,,,127.31,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 4.0 X 42,17703,CDM,0278,RC,,,,,,inpatient,facility,,,332.64,332.64,149.69,332.64,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,249.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.08,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,216.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 4.0 X 42,17703,CDM,0278,RC,,,,,,outpatient,facility,,,332.64,332.64,63.2,332.64,,216.22,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,99.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.48,,,percent of total billed charges,,,,,,232.85,,,percent of total billed charges,,,,,,232.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,216.22,,,percent of total billed charges,,,,,,79.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,332.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.85,,,percent of total billed charges,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,232.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,236.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.85,,,percent of total billed charges,,,,,,199.58,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,282.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,143.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,332.64,,,percent of total billed charges,,,,,,149.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,,fee schedule,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,332.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,332.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282.74,,,percent of total billed charges,,,,,,249.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR LT TI 7H 2.0 X 39,17798,CDM,0278,RC,,,,,,inpatient,facility,,,600.6,600.6,270.27,600.6,,,,,,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,450.45,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",426.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,420.42,,,percent of total billed charges,,,,,,360.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,330.33,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,270.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,390.39,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR LT TI 7H 2.0 X 39,17798,CDM,0278,RC,,,,,,outpatient,facility,,,600.6,600.6,114.11,600.6,,390.39,,,percent of total billed charges,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,180.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,282.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,114.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,114.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,450.46,,,percent of total billed charges,,,,,,420.42,,,percent of total billed charges,,,,,,420.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,390.39,,,percent of total billed charges,,,,,,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,600.6,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,252.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",420.42,,,percent of total billed charges,,,,,,,,,,,,,,,600.6,,,percent of total billed charges,,,,,,418.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,426.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,420.42,,,percent of total billed charges,,,,,,360.36,,,percent of total billed charges,,,,,,270.27,,,percent of total billed charges,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,600.6,,,percent of total billed charges,,,,,,600.6,,,percent of total billed charges,,,,,,330.33,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.45,,,percent of total billed charges,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,600.6,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,600.6,,,percent of total billed charges,,,,,,270.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,,fee schedule,,,,,,600.6,,,percent of total billed charges,,,,,,600.6,,,percent of total billed charges,,,,,,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,510.51,,,percent of total billed charges,,,,,,450.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR RT TI 7H 2.0 X 39,17799,CDM,0278,RC,,,,,,inpatient,facility,,,600.6,600.6,270.27,600.6,,,,,,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,450.45,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",426.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,420.42,,,percent of total billed charges,,,,,,360.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,330.33,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,270.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,390.39,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR RT TI 7H 2.0 X 39,17799,CDM,0278,RC,,,,,,outpatient,facility,,,600.6,600.6,114.11,600.6,,390.39,,,percent of total billed charges,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,180.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,282.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,114.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,114.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,450.46,,,percent of total billed charges,,,,,,420.42,,,percent of total billed charges,,,,,,420.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,390.39,,,percent of total billed charges,,,,,,330.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,600.6,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,252.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",420.42,,,percent of total billed charges,,,,,,,,,,,,,,,600.6,,,percent of total billed charges,,,,,,418.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,426.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,420.42,,,percent of total billed charges,,,,,,360.36,,,percent of total billed charges,,,,,,270.27,,,percent of total billed charges,,,,,,,,,,,,,,,510.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,600.6,,,percent of total billed charges,,,,,,600.6,,,percent of total billed charges,,,,,,330.33,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.45,,,percent of total billed charges,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,600.6,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,600.6,,,percent of total billed charges,,,,,,270.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,,fee schedule,,,,,,600.6,,,percent of total billed charges,,,,,,600.6,,,percent of total billed charges,,,,,,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,600.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,510.51,,,percent of total billed charges,,,,,,450.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI L OBLIQUE LT TI 3H 2.7 X 34,17821,CDM,0278,RC,,,,,,inpatient,facility,,,123.42,123.42,55.54,123.42,,,,,,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,92.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.61,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",87.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,55.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,80.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI L OBLIQUE LT TI 3H 2.7 X 34,17821,CDM,0278,RC,,,,,,outpatient,facility,,,123.42,123.42,23.45,138.8,,80.22,,,percent of total billed charges,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,37.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,58.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.88,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,23.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.88,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.88,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,67.88,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.57,,,percent of total billed charges,,,,,,86.39,,,percent of total billed charges,,,,,,86.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,80.22,,,percent of total billed charges,,,,,,29.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,123.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,51.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",86.39,,,percent of total billed charges,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,86.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,87.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,74.05,,,percent of total billed charges,,,,,,55.54,,,percent of total billed charges,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,123.42,,,percent of total billed charges,,,,,,53.07,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.56,,,percent of total billed charges,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,123.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,123.42,,,percent of total billed charges,,,,,,55.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,fee schedule,,,,,,123.42,,,percent of total billed charges,,,,,,123.42,,,percent of total billed charges,,,,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,104.91,,,percent of total billed charges,,,,,,92.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI L OBLIQUE RT TI 3H 2.7 X 34,17822,CDM,0278,RC,,,,,,inpatient,facility,,,123.42,123.42,55.54,123.42,,,,,,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,92.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.61,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",87.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,74.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,55.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,80.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI L OBLIQUE RT TI 3H 2.7 X 34,17822,CDM,0278,RC,,,,,,outpatient,facility,,,123.42,123.42,23.45,138.8,,80.22,,,percent of total billed charges,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,37.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,58.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.88,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,23.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.88,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.88,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,67.88,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.57,,,percent of total billed charges,,,,,,86.39,,,percent of total billed charges,,,,,,86.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,80.22,,,percent of total billed charges,,,,,,29.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,123.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,51.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",86.39,,,percent of total billed charges,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,86.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,87.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,86.39,,,percent of total billed charges,,,,,,74.05,,,percent of total billed charges,,,,,,55.54,,,percent of total billed charges,,,,,,,,,,,,,,,104.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,123.42,,,percent of total billed charges,,,,,,53.07,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.56,,,percent of total billed charges,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,123.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,123.42,,,percent of total billed charges,,,,,,55.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,,fee schedule,,,,,,123.42,,,percent of total billed charges,,,,,,123.42,,,percent of total billed charges,,,,,,123.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,123.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,104.91,,,percent of total billed charges,,,,,,92.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR LT TI 7H 2.7 X 57,17823,CDM,0278,RC,,,,,,inpatient,facility,,,662.64,662.64,298.19,662.64,,,,,,,,,,,,,,,,,,,,563.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,496.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",470.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,463.85,,,percent of total billed charges,,,,,,397.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,563.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.45,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,364.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,662.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,662.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,298.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,563.24,,,percent of total billed charges,,,,,,430.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR LT TI 7H 2.7 X 57,17823,CDM,0278,RC,,,,,,outpatient,facility,,,662.64,662.64,125.9,662.64,,430.72,,,percent of total billed charges,,,,,,,,,,,,,,,563.24,,,percent of total billed charges,,,,,,198.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,311.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.45,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,125.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,125.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,364.45,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,364.45,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,364.45,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,496.98,,,percent of total billed charges,,,,,,463.85,,,percent of total billed charges,,,,,,463.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,430.72,,,percent of total billed charges,,,,,,364.45,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,662.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,278.31,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",463.85,,,percent of total billed charges,,,,,,,,,,,,,,,662.64,,,percent of total billed charges,,,,,,462.19,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,470.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,463.85,,,percent of total billed charges,,,,,,397.58,,,percent of total billed charges,,,,,,298.19,,,percent of total billed charges,,,,,,,,,,,,,,,563.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.45,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,662.64,,,percent of total billed charges,,,,,,662.64,,,percent of total billed charges,,,,,,364.45,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,662.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,662.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.98,,,percent of total billed charges,,,,,,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,662.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,662.64,,,percent of total billed charges,,,,,,298.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,496.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,662.64,,,fee schedule,,,,,,662.64,,,percent of total billed charges,,,,,,662.64,,,percent of total billed charges,,,,,,662.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,662.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,563.24,,,percent of total billed charges,,,,,,496.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX ST STRT 8SH 4FR .035 X 65  i,17865,CDM,0272,RC,,,,,,inpatient,facility,,,47.77,47.77,21.5,47.77,,,,,,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,33.44,,,percent of total billed charges,,,,,,28.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX ST STRT 8SH 4FR .035 X 65  i,17865,CDM,0272,RC,,,,,,outpatient,facility,,,47.77,47.77,9.08,1016,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,14.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,9.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,9.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.82,,,percent of total billed charges,,,,,,33.44,,,percent of total billed charges,,,,,,33.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,11.46,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.24,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,47.77,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,20.06,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",33.44,,,percent of total billed charges,,,,,,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,33.32,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,33.44,,,percent of total billed charges,,,,,,28.66,,,percent of total billed charges,,,,,,21.5,,,percent of total billed charges,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,47.77,,,percent of total billed charges,,,,,,20.54,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,47.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,47.77,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,47.77,,,percent of total billed charges,,,,,,21.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,,fee schedule,,,,,,47.77,,,percent of total billed charges,,,,,,47.77,,,percent of total billed charges,,,,,,47.77,,,percent of total billed charges,,,,,,22.93,,,percent of total billed charges,,,,,,,,,,,,,,,28.18,,,percent of total billed charges,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.6,,,percent of total billed charges,,,,,,35.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC NSY SUPPPORTIVE CARE,17900001,CDM,0179,RC,,,,,,inpatient,facility,,,550,550,247.5,7000,,1124,,,per diem,,,,,,550,,,fee schedule,,,,,,467.5,,,percent of total billed charges,,,,,,,,,,,,,,,658,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,550,,,case rate,,,,,,550,,,case rate,,,,,,550,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,550,,,case rate,,,,,,1960,,,per diem,,,,,,412.5,,,percent of total billed charges,,,,,,385,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,275,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,275,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,357.5,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,550,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,385,,,percent of total billed charges,,,,,,,,,,,,,,,550,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",390.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,385,,,percent of total billed charges,,,,,,330,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550,,,percent of total billed charges,,,,,,550,,,percent of total billed charges,,,,,,520,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330,,,percent of total billed charges,,,,,,550,,,fee schedule,,,,,,550,,,fee schedule,,,,,,550,,,fee schedule,,,,,,550,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,550,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,412.5,,,percent of total billed charges,,,,,,550,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,550,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,550,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,550,,,percent of total billed charges,,,,,,,,,,,,,,,550,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,550,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,550,,,percent of total billed charges,,,,,,247.5,,,percent of total billed charges,,,,,,,,,,,,,,,550,,,fee schedule,,,,,,,,,,,,,,,550,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,550,,,fee schedule,,,,,,,,,,,,,,,550,,,fee schedule,,,,,,,,,,,,,,,330,,,percent of total billed charges,,,,,,550,,,percent of total billed charges,,,,,,330,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,550,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,467.5,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
CATH DRAIN FLEXIMA NEPH REG PIG 8FR 25CM  i,17973,CDM,0272,RC,,,,,,inpatient,facility,,,276.5,276.5,124.42,276.5,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DRAIN FLEXIMA NEPH REG PIG 8FR 25CM  i,17973,CDM,0272,RC,,,,,,outpatient,facility,,,276.5,276.5,52.54,1016,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,82.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,129.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,207.38,,,percent of total billed charges,,,,,,193.55,,,percent of total billed charges,,,,,,193.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,66.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",186.64,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.13,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",193.55,,,percent of total billed charges,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,192.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,118.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,fee schedule,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,132.72,,,percent of total billed charges,,,,,,,,,,,,,,,163.13,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,235.02,,,percent of total billed charges,,,,,,207.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH ERCP GLO TIP STD 5.5FR 100 X 200,17980,CDM,0272,RC,,,,,,inpatient,facility,,,217,217,97.65,217,,,,,,,,,,,,,,,,,,,,184.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,151.9,,,percent of total billed charges,,,,,,130.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,184.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,217,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,97.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.45,,,percent of total billed charges,,,,,,,,,,,,,,
CATH ERCP GLO TIP STD 5.5FR 100 X 200,17980,CDM,0272,RC,,,,,,outpatient,facility,,,217,217,41.23,1016,,141.05,,,percent of total billed charges,,,,,,,,,,,,,,,184.45,,,percent of total billed charges,,,,,,65.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,101.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,162.75,,,percent of total billed charges,,,,,,151.9,,,percent of total billed charges,,,,,,151.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,141.05,,,percent of total billed charges,,,,,,52.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",146.47,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,217,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,91.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",151.9,,,percent of total billed charges,,,,,,,,,,,,,,,217,,,percent of total billed charges,,,,,,151.36,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,154.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,151.9,,,percent of total billed charges,,,,,,130.2,,,percent of total billed charges,,,,,,97.65,,,percent of total billed charges,,,,,,,,,,,,,,,184.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217,,,percent of total billed charges,,,,,,217,,,percent of total billed charges,,,,,,93.31,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,217,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,217,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.75,,,percent of total billed charges,,,,,,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,217,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,217,,,percent of total billed charges,,,,,,97.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217,,,fee schedule,,,,,,217,,,percent of total billed charges,,,,,,217,,,percent of total billed charges,,,,,,217,,,percent of total billed charges,,,,,,104.16,,,percent of total billed charges,,,,,,,,,,,,,,,128.03,,,percent of total billed charges,,,,,,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,217,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.45,,,percent of total billed charges,,,,,,162.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC LOA ROOM HOLD,18000001,CDM,0180,RC,,,,,,inpatient,facility,,,1,1,0.45,7000,,3538,,,per diem,,,,,,1,,,fee schedule,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,1989,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,1,,,case rate,,,,,,1,,,case rate,,,,,,1,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,case rate,,,,,,1960,,,per diem,,,,,,0.75,,,percent of total billed charges,,,,,,0.7,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,0.5,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,0.5,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,1,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,6510,,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$7,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,3000,,,per diem,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1754,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,1,,,fee schedule,,,,,,1,,,fee schedule,,,,,,1,,,fee schedule,,,,,,1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,,,,,,,,,,0.6,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,0.85,,,percent of total billed charges,,,,,,7000,,,per diem,,,,,
WATER IRRIG BT STRL 1000ML  i,18067,CDM,0272,RC,,,,,,inpatient,facility,,,6.71,6.71,3.02,6.71,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,
WATER IRRIG BT STRL 1000ML  i,18067,CDM,0272,RC,,,,,,outpatient,facility,,,6.71,6.71,1.27,1016,,4.36,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,2.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,5.03,,,percent of total billed charges,,,,,,4.7,,,percent of total billed charges,,,,,,4.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4.36,,,percent of total billed charges,,,,,,1.61,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.53,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6.71,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.82,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.7,,,percent of total billed charges,,,,,,,,,,,,,,,6.71,,,percent of total billed charges,,,,,,4.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,4.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.7,,,percent of total billed charges,,,,,,4.03,,,percent of total billed charges,,,,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,5.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.71,,,percent of total billed charges,,,,,,6.71,,,percent of total billed charges,,,,,,2.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,6.71,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,6.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.71,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.71,,,percent of total billed charges,,,,,,3.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.71,,,fee schedule,,,,,,6.71,,,percent of total billed charges,,,,,,6.71,,,percent of total billed charges,,,,,,6.71,,,percent of total billed charges,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,3.96,,,percent of total billed charges,,,,,,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.7,,,percent of total billed charges,,,,,,5.03,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CEMENT STR BONE SIMPLEX P  i,18162,CDM,0278,RC,,,,,,inpatient,facility,,,148.62,148.62,66.88,148.62,,,,,,,,,,,,,,,,,,,,126.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,111.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.84,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",105.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,104.03,,,percent of total billed charges,,,,,,89.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,126.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,148.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,66.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.33,,,percent of total billed charges,,,,,,96.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CEMENT STR BONE SIMPLEX P  i,18162,CDM,0278,RC,,,,,,outpatient,facility,,,148.62,148.62,28.24,148.62,,96.6,,,percent of total billed charges,,,,,,,,,,,,,,,126.33,,,percent of total billed charges,,,,,,44.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,69.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,28.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,28.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,81.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,81.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,111.47,,,percent of total billed charges,,,,,,104.03,,,percent of total billed charges,,,,,,104.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,96.6,,,percent of total billed charges,,,,,,35.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,148.62,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,62.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",104.03,,,percent of total billed charges,,,,,,,,,,,,,,,148.62,,,percent of total billed charges,,,,,,103.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,105.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,104.03,,,percent of total billed charges,,,,,,89.17,,,percent of total billed charges,,,,,,66.88,,,percent of total billed charges,,,,,,,,,,,,,,,126.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.62,,,percent of total billed charges,,,,,,148.62,,,percent of total billed charges,,,,,,63.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,148.62,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,148.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.46,,,percent of total billed charges,,,,,,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.62,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,148.62,,,percent of total billed charges,,,,,,66.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.62,,,fee schedule,,,,,,148.62,,,percent of total billed charges,,,,,,148.62,,,percent of total billed charges,,,,,,148.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,148.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,126.33,,,percent of total billed charges,,,,,,111.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JR4 5FR 100CM  ORDER SETS OF 5,18315,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JR4 5FR 100CM  ORDER SETS OF 5,18315,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ENDOTRACH N CUFF 2.5M 8F,18317,CDM,0272,RC,,,,,,inpatient,facility,,,4.53,4.53,2.04,4.53,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ENDOTRACH N CUFF 2.5M 8F,18317,CDM,0272,RC,,,,,,outpatient,facility,,,4.53,4.53,0.86,1016,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.4,,,percent of total billed charges,,,,,,3.17,,,percent of total billed charges,,,,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,1.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.06,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,3.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,1.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,fee schedule,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.85,,,percent of total billed charges,,,,,,3.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE CHANGER ENDOTRACH 5.5,18324,CDM,0270,RC,,,,,,inpatient,facility,,,41.65,41.65,18.74,41.65,,,,,,,,,,,,,,,,,,,,35.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,29.16,,,percent of total billed charges,,,,,,24.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,35.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,18.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.4,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE CHANGER ENDOTRACH 5.5,18324,CDM,0270,RC,,,,,,outpatient,facility,,,41.65,41.65,7.91,1016,,27.07,,,percent of total billed charges,,,,,,,,,,,,,,,35.4,,,percent of total billed charges,,,,,,12.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,19.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,7.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,31.23,,,percent of total billed charges,,,,,,29.16,,,percent of total billed charges,,,,,,29.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,27.07,,,percent of total billed charges,,,,,,10,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",28.11,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,41.65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,17.49,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",29.15,,,percent of total billed charges,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,,,,29.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,29.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,29.16,,,percent of total billed charges,,,,,,24.99,,,percent of total billed charges,,,,,,18.74,,,percent of total billed charges,,,,,,,,,,,,,,,35.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,,,,41.65,,,percent of total billed charges,,,,,,17.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,41.65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.24,,,percent of total billed charges,,,,,,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,41.65,,,percent of total billed charges,,,,,,18.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.65,,,fee schedule,,,,,,41.65,,,percent of total billed charges,,,,,,41.65,,,percent of total billed charges,,,,,,41.65,,,percent of total billed charges,,,,,,19.99,,,percent of total billed charges,,,,,,,,,,,,,,,24.57,,,percent of total billed charges,,,,,,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,41.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,35.4,,,percent of total billed charges,,,,,,31.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE SYN TH 1.25 X 150 F 4.0MM CANN SCREWS,18326,CDM,0272,RC,,,,,,inpatient,facility,,,83.16,83.16,37.42,83.16,,,,,,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.21,,,percent of total billed charges,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE SYN TH 1.25 X 150 F 4.0MM CANN SCREWS,18326,CDM,0272,RC,,,,,,outpatient,facility,,,83.16,83.16,15.8,1016,,54.05,,,percent of total billed charges,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,24.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,39.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,15.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,62.37,,,percent of total billed charges,,,,,,58.21,,,percent of total billed charges,,,,,,58.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,54.05,,,percent of total billed charges,,,,,,19.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",56.13,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,83.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.93,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",58.21,,,percent of total billed charges,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,59.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.21,,,percent of total billed charges,,,,,,49.9,,,percent of total billed charges,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,83.16,,,percent of total billed charges,,,,,,35.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,83.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,83.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,83.16,,,percent of total billed charges,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,fee schedule,,,,,,83.16,,,percent of total billed charges,,,,,,83.16,,,percent of total billed charges,,,,,,83.16,,,percent of total billed charges,,,,,,39.92,,,percent of total billed charges,,,,,,,,,,,,,,,49.06,,,percent of total billed charges,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.69,,,percent of total billed charges,,,,,,62.37,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DRAIN FLEXIMA APD LOOP FIRM 8FR 25CM  i,18343,CDM,0272,RC,,,,,,inpatient,facility,,,276.5,276.5,124.42,276.5,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DRAIN FLEXIMA APD LOOP FIRM 8FR 25CM  i,18343,CDM,0272,RC,,,,,,outpatient,facility,,,276.5,276.5,52.54,1016,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,82.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,129.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,207.38,,,percent of total billed charges,,,,,,193.55,,,percent of total billed charges,,,,,,193.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,66.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",186.64,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.13,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",193.55,,,percent of total billed charges,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,192.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,118.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,fee schedule,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,132.72,,,percent of total billed charges,,,,,,,,,,,,,,,163.13,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,235.02,,,percent of total billed charges,,,,,,207.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DRAIN FLEXIMA APD LOOP REG 14FR 25CM  i,18344,CDM,0272,RC,,,,,,inpatient,facility,,,276.5,276.5,124.42,276.5,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DRAIN FLEXIMA APD LOOP REG 14FR 25CM  i,18344,CDM,0272,RC,,,,,,outpatient,facility,,,276.5,276.5,52.54,1016,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,82.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,129.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,207.38,,,percent of total billed charges,,,,,,193.55,,,percent of total billed charges,,,,,,193.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,66.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",186.64,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.13,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",193.55,,,percent of total billed charges,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,192.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,118.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,fee schedule,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,132.72,,,percent of total billed charges,,,,,,,,,,,,,,,163.13,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,235.02,,,percent of total billed charges,,,,,,207.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DRAIN FLEXIMA APD LOOP REG 12FR 25CM  i,18346,CDM,0272,RC,,,,,,inpatient,facility,,,276.5,276.5,124.42,276.5,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DRAIN FLEXIMA APD LOOP REG 12FR 25CM  i,18346,CDM,0272,RC,,,,,,outpatient,facility,,,276.5,276.5,52.54,1016,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,82.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,129.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,207.38,,,percent of total billed charges,,,,,,193.55,,,percent of total billed charges,,,,,,193.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,66.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",186.64,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.13,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",193.55,,,percent of total billed charges,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,192.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,118.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,fee schedule,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,132.72,,,percent of total billed charges,,,,,,,,,,,,,,,163.13,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,235.02,,,percent of total billed charges,,,,,,207.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRAINAGE LUMBAR HERMETIC CLOSED TIP  i,18358,CDM,0272,RC,,,,,,inpatient,facility,,,628.11,628.11,282.65,628.11,,,,,,,,,,,,,,,,,,,,533.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,408.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,445.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,439.68,,,percent of total billed charges,,,,,,376.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,533.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,628.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,282.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,533.89,,,percent of total billed charges,,,,,,,,,,,,,,
DRAINAGE LUMBAR HERMETIC CLOSED TIP  i,18358,CDM,0272,RC,,,,,,outpatient,facility,,,628.11,628.11,119.34,1016,,408.27,,,percent of total billed charges,,,,,,,,,,,,,,,533.89,,,percent of total billed charges,,,,,,188.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,295.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,119.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,119.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,471.08,,,percent of total billed charges,,,,,,439.68,,,percent of total billed charges,,,,,,439.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,408.27,,,percent of total billed charges,,,,,,150.75,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",423.97,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,628.11,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,263.81,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",439.68,,,percent of total billed charges,,,,,,,,,,,,,,,628.11,,,percent of total billed charges,,,,,,438.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,445.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,439.68,,,percent of total billed charges,,,,,,376.87,,,percent of total billed charges,,,,,,282.65,,,percent of total billed charges,,,,,,,,,,,,,,,533.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.11,,,percent of total billed charges,,,,,,628.11,,,percent of total billed charges,,,,,,270.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,628.11,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,628.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.08,,,percent of total billed charges,,,,,,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,628.11,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,628.11,,,percent of total billed charges,,,,,,282.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,471.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,628.11,,,fee schedule,,,,,,628.11,,,percent of total billed charges,,,,,,628.11,,,percent of total billed charges,,,,,,628.11,,,percent of total billed charges,,,,,,301.49,,,percent of total billed charges,,,,,,,,,,,,,,,370.58,,,percent of total billed charges,,,,,,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,628.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,533.89,,,percent of total billed charges,,,,,,471.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRAINAGE VENTRICULAR EXTNL  i,18359,CDM,0272,RC,,,,,,inpatient,facility,,,550.93,550.93,247.92,550.93,,,,,,,,,,,,,,,,,,,,468.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,385.65,,,percent of total billed charges,,,,,,330.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,468.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,550.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,468.29,,,percent of total billed charges,,,,,,,,,,,,,,
DRAINAGE VENTRICULAR EXTNL  i,18359,CDM,0272,RC,,,,,,outpatient,facility,,,550.93,550.93,104.68,1016,,358.1,,,percent of total billed charges,,,,,,,,,,,,,,,468.29,,,percent of total billed charges,,,,,,165.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,258.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,104.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,104.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,413.2,,,percent of total billed charges,,,,,,385.65,,,percent of total billed charges,,,,,,385.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,358.1,,,percent of total billed charges,,,,,,132.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",371.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.93,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,231.39,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",385.65,,,percent of total billed charges,,,,,,,,,,,,,,,550.93,,,percent of total billed charges,,,,,,384.27,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,391.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,385.65,,,percent of total billed charges,,,,,,330.56,,,percent of total billed charges,,,,,,247.92,,,percent of total billed charges,,,,,,,,,,,,,,,468.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.93,,,percent of total billed charges,,,,,,550.93,,,percent of total billed charges,,,,,,236.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,550.93,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,550.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.2,,,percent of total billed charges,,,,,,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,550.93,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,550.93,,,percent of total billed charges,,,,,,247.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,413.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.93,,,fee schedule,,,,,,550.93,,,percent of total billed charges,,,,,,550.93,,,percent of total billed charges,,,,,,550.93,,,percent of total billed charges,,,,,,264.45,,,percent of total billed charges,,,,,,,,,,,,,,,325.05,,,percent of total billed charges,,,,,,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,468.29,,,percent of total billed charges,,,,,,413.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SET COLON DECOMPRESSION 14.0FR 175CM,18371,CDM,0272,RC,,,,,,inpatient,facility,,,511,511,229.95,511,,,,,,,,,,,,,,,,,,,,434.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,332.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,362.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,357.7,,,percent of total billed charges,,,,,,306.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,434.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,511,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,229.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.35,,,percent of total billed charges,,,,,,,,,,,,,,
SET COLON DECOMPRESSION 14.0FR 175CM,18371,CDM,0272,RC,,,,,,outpatient,facility,,,511,511,97.09,1016,,332.15,,,percent of total billed charges,,,,,,,,,,,,,,,434.35,,,percent of total billed charges,,,,,,153.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,240.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,97.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,383.25,,,percent of total billed charges,,,,,,357.7,,,percent of total billed charges,,,,,,357.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,332.15,,,percent of total billed charges,,,,,,122.64,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",344.93,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,511,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,214.62,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",357.7,,,percent of total billed charges,,,,,,,,,,,,,,,511,,,percent of total billed charges,,,,,,356.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,362.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,357.7,,,percent of total billed charges,,,,,,306.6,,,percent of total billed charges,,,,,,229.95,,,percent of total billed charges,,,,,,,,,,,,,,,434.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511,,,percent of total billed charges,,,,,,511,,,percent of total billed charges,,,,,,219.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,511,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,511,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.25,,,percent of total billed charges,,,,,,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,511,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,511,,,percent of total billed charges,,,,,,229.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,383.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511,,,fee schedule,,,,,,511,,,percent of total billed charges,,,,,,511,,,percent of total billed charges,,,,,,511,,,percent of total billed charges,,,,,,245.28,,,percent of total billed charges,,,,,,,,,,,,,,,301.49,,,percent of total billed charges,,,,,,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,511,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,434.35,,,percent of total billed charges,,,,,,383.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL SMI HIP REFLECTION V 44MM,18559,CDM,0278,RC,,,,,,inpatient,facility,,,3161,3161,1422.45,3161,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2686.85,,,percent of total billed charges,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2528.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2370.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1738.55,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1910.82,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2244.31,,,percent of total billed charges,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2212.7,,,percent of total billed charges,,,,,,1896.6,,,percent of total billed charges,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2686.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1738.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3161,,,percent of total billed charges,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2370.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3161,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1422.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2686.85,,,percent of total billed charges,,,,,,2054.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL SMI HIP REFLECTION V 44MM,18559,CDM,0278,RC,,,,,,outpatient,facility,,,3161,3161,129.72,3161,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2686.85,,,percent of total billed charges,,,,,,948.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,600.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,600.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2370.75,,,percent of total billed charges,,,,,,2212.7,,,percent of total billed charges,,,,,,2212.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2054.65,,,percent of total billed charges,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3161,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2212.7,,,percent of total billed charges,,,,,,1738.55,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3161,,,percent of total billed charges,,,,,,2204.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2244.31,,,percent of total billed charges,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2212.7,,,percent of total billed charges,,,,,,1896.6,,,percent of total billed charges,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2686.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1738.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3161,,,percent of total billed charges,,,,,,3161,,,percent of total billed charges,,,,,,1738.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3161,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3161,,,percent of total billed charges,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2370.75,,,percent of total billed charges,,,,,,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3161,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3161,,,percent of total billed charges,,,,,,1422.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2370.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3161,,,fee schedule,,,,,,3161,,,percent of total billed charges,,,,,,3161,,,percent of total billed charges,,,,,,3161,,,percent of total billed charges,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1738.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3161,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2686.85,,,percent of total billed charges,,,,,,2370.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FOOD SUPPLEMNTLACTOREDUCE 0.05 GRAM1.2 KCALML LIQU,186175,CDM,0250,RC,,,,,,inpatient,facility,1000,ML,19,19,8.55,19,,,,,,,,,,,,,,,,,,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13.3,,,percent of total billed charges,,,,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,
FOOD SUPPLEMNTLACTOREDUCE 0.05 GRAM1.2 KCALML LIQU,186175,CDM,0250,RC,,,,,,outpatient,facility,1000,ML,19,19,3.61,1016,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,16.15,,,percent of total billed charges,,,,,,5.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,14.25,,,percent of total billed charges,,,,,,13.3,,,percent of total billed charges,,,,,,13.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,12.35,,,percent of total billed charges,,,,,,4.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",12.83,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,19,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",13.3,,,percent of total billed charges,,,,,,,,,,,,,,,19,,,percent of total billed charges,,,,,,13.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13.3,,,percent of total billed charges,,,,,,11.4,,,percent of total billed charges,,,,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19,,,percent of total billed charges,,,,,,19,,,percent of total billed charges,,,,,,8.17,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,19,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,19,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,19,,,percent of total billed charges,,,,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19,,,fee schedule,,,,,,19,,,percent of total billed charges,,,,,,19,,,percent of total billed charges,,,,,,19,,,percent of total billed charges,,,,,,9.12,,,percent of total billed charges,,,,,,,,,,,,,,,11.21,,,percent of total billed charges,,,,,,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,19,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.15,,,percent of total billed charges,,,,,,14.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE AMPLZ S STIFF STRT SHRT .035 X 4 X 145  i,18646,CDM,0272,RC,,,,,,inpatient,facility,,,93.66,93.66,42.15,93.66,,,,,,,,,,,,,,,,,,,,79.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.56,,,percent of total billed charges,,,,,,56.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,79.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,93.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,42.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.61,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE AMPLZ S STIFF STRT SHRT .035 X 4 X 145  i,18646,CDM,0272,RC,,,,,,outpatient,facility,,,93.66,93.66,17.8,1016,,60.88,,,percent of total billed charges,,,,,,,,,,,,,,,79.61,,,percent of total billed charges,,,,,,28.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,44.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,17.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,70.24,,,percent of total billed charges,,,,,,65.56,,,percent of total billed charges,,,,,,65.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,60.88,,,percent of total billed charges,,,,,,22.48,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",63.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,93.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.34,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",65.56,,,percent of total billed charges,,,,,,,,,,,,,,,93.66,,,percent of total billed charges,,,,,,65.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.56,,,percent of total billed charges,,,,,,56.2,,,percent of total billed charges,,,,,,42.15,,,percent of total billed charges,,,,,,,,,,,,,,,79.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.66,,,percent of total billed charges,,,,,,93.66,,,percent of total billed charges,,,,,,40.27,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,93.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,93.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.24,,,percent of total billed charges,,,,,,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.66,,,percent of total billed charges,,,,,,42.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.66,,,fee schedule,,,,,,93.66,,,percent of total billed charges,,,,,,93.66,,,percent of total billed charges,,,,,,93.66,,,percent of total billed charges,,,,,,44.96,,,percent of total billed charges,,,,,,,,,,,,,,,55.26,,,percent of total billed charges,,,,,,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,93.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,79.61,,,percent of total billed charges,,,,,,70.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN W STOP 3.0 X 14,18715,CDM,0272,RC,,,,,,inpatient,facility,,,1242.5,1242.5,559.13,1242.5,,,,,,,,,,,,,,,,,,,,1056.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,931.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,807.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,882.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,869.75,,,percent of total billed charges,,,,,,745.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1056.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1242.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,931.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1242.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,559.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.12,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN W STOP 3.0 X 14,18715,CDM,0272,RC,,,,,,outpatient,facility,,,1242.5,1242.5,129.72,1242.5,,807.63,,,percent of total billed charges,,,,,,,,,,,,,,,1056.12,,,percent of total billed charges,,,,,,372.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,583.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,236.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,236.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,931.88,,,percent of total billed charges,,,,,,869.75,,,percent of total billed charges,,,,,,869.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,807.63,,,percent of total billed charges,,,,,,298.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",838.69,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1242.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,521.85,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",869.75,,,percent of total billed charges,,,,,,,,,,,,,,,1242.5,,,percent of total billed charges,,,,,,866.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,882.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,869.75,,,percent of total billed charges,,,,,,745.5,,,percent of total billed charges,,,,,,559.13,,,percent of total billed charges,,,,,,,,,,,,,,,1056.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1242.5,,,percent of total billed charges,,,,,,1242.5,,,percent of total billed charges,,,,,,534.27,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1242.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1242.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,931.88,,,percent of total billed charges,,,,,,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1242.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1242.5,,,percent of total billed charges,,,,,,559.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,931.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1242.5,,,fee schedule,,,,,,1242.5,,,percent of total billed charges,,,,,,1242.5,,,percent of total billed charges,,,,,,1242.5,,,percent of total billed charges,,,,,,596.4,,,percent of total billed charges,,,,,,,,,,,,,,,733.08,,,percent of total billed charges,,,,,,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1242.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1056.12,,,percent of total billed charges,,,,,,931.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 8X120,18754,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 8X120,18754,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 9X125,18755,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 9X125,18755,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 10X130,18756,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 10X130,18756,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 11X135,18757,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 11X135,18757,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 12X140,18758,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 12X140,18758,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 13X145,18759,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 13X145,18759,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 14X150,18760,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 14X150,18760,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 15X155,18761,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 15X155,18761,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 16X160,18762,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 16X160,18762,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COLLAR BIOMET FEM HIP 17X165,18763,CDM,0278,RC,,,,,,inpatient,facility,,,7458,7458,3356.1,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5966.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5593.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4508.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7458,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,4847.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
COLLAR BIOMET FEM HIP 17X165,18763,CDM,0278,RC,,,,,,outpatient,facility,,,7458,7458,129.72,7458,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6339.3,,,percent of total billed charges,,,,,,2237.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1417.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5593.5,,,percent of total billed charges,,,,,,5220.6,,,percent of total billed charges,,,,,,5220.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4847.7,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,7458,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,5201.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5295.18,,,percent of total billed charges,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5220.6,,,percent of total billed charges,,,,,,4474.8,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6339.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7458,,,percent of total billed charges,,,,,,3356.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5593.5,,,percent of total billed charges,,,,,,4101.9,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7458,,,fee schedule,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,7458,,,percent of total billed charges,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4101.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7458,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6339.3,,,percent of total billed charges,,,,,,5593.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STENT SET BILIARY COTTON LEUNG 8.5FR 7CM,18806,CDM,0278,RC,,,,,,inpatient,facility,,,258,258,116.1,258,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,193.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,167.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STENT SET BILIARY COTTON LEUNG 8.5FR 7CM,18806,CDM,0278,RC,,,,,,outpatient,facility,,,258,258,49.02,258,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,77.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,121.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,,percent of total billed charges,,,,,,180.6,,,percent of total billed charges,,,,,,180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,61.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",180.6,,,percent of total billed charges,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,179.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,110.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,fee schedule,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.3,,,percent of total billed charges,,,,,,193.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STENT SET BILIARY COTTON LEUNG 8.5FR 9CM,18807,CDM,0278,RC,,,,,,inpatient,facility,,,258,258,116.1,258,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,193.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,167.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STENT SET BILIARY COTTON LEUNG 8.5FR 9CM,18807,CDM,0278,RC,,,,,,outpatient,facility,,,258,258,49.02,258,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,77.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,121.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,,percent of total billed charges,,,,,,180.6,,,percent of total billed charges,,,,,,180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,61.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",180.6,,,percent of total billed charges,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,179.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,110.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,fee schedule,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.3,,,percent of total billed charges,,,,,,193.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CABLE STR SLEEVE DALL MILES SS 2.0MM  i,18835,CDM,0278,RC,,,,,,inpatient,facility,,,813,813,365.85,813,,,,,,,,,,,,,,,,,,,,691.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,609.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,447.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,491.46,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",577.23,,,percent of total billed charges,,,,,,,,,,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,569.1,,,percent of total billed charges,,,,,,487.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,691.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,447.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813,,,percent of total billed charges,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,609.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,813,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,365.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,691.05,,,percent of total billed charges,,,,,,528.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CABLE STR SLEEVE DALL MILES SS 2.0MM  i,18835,CDM,0278,RC,,,,,,outpatient,facility,,,813,813,129.72,813,,528.45,,,percent of total billed charges,,,,,,,,,,,,,,,691.05,,,percent of total billed charges,,,,,,243.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,382.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,154.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,154.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,609.75,,,percent of total billed charges,,,,,,569.1,,,percent of total billed charges,,,,,,569.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,528.45,,,percent of total billed charges,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,813,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,569.1,,,percent of total billed charges,,,,,,447.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,813,,,percent of total billed charges,,,,,,567.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,577.23,,,percent of total billed charges,,,,,,,,,,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,569.1,,,percent of total billed charges,,,,,,487.8,,,percent of total billed charges,,,,,,365.85,,,percent of total billed charges,,,,,,,,,,,,,,,691.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,813,,,percent of total billed charges,,,,,,813,,,percent of total billed charges,,,,,,447.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,813,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,813,,,percent of total billed charges,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,609.75,,,percent of total billed charges,,,,,,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,813,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,813,,,percent of total billed charges,,,,,,365.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,609.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,447.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,813,,,fee schedule,,,,,,813,,,percent of total billed charges,,,,,,813,,,percent of total billed charges,,,,,,813,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,691.05,,,percent of total billed charges,,,,,,609.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 7 X 11 X 155,18839,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 7 X 11 X 155,18839,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 7 X 13 X 155,18840,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 7 X 13 X 155,18840,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 8 X 12 X 155,18841,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 8 X 12 X 155,18841,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 8 X 14 X 155,18842,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 8 X 14 X 155,18842,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 9 X 13 X 155,18843,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 9 X 13 X 155,18843,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 9 X 15 X 155,18844,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 9 X 15 X 155,18844,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 10 X 14 X 155,18845,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 10 X 14 X 155,18845,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 10 X 16 X 155,18846,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 10 X 16 X 155,18846,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 11 X 15 X 155,18847,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 11 X 15 X 155,18847,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 11 X 17 X 155,18848,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 11 X 17 X 155,18848,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 12 X 16 X 155,18849,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 12 X 16 X 155,18849,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 12 X 18 X 155,18850,CDM,0278,RC,,,,,,inpatient,facility,,,14188,14188,6384.6,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11350.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10641,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8576.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,14188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,9222.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 12 X 18 X 155,18850,CDM,0278,RC,,,,,,outpatient,facility,,,14188,14188,129.72,14188,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12059.8,,,percent of total billed charges,,,,,,4256.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2695.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10641,,,percent of total billed charges,,,,,,9931.6,,,percent of total billed charges,,,,,,9931.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,9222.2,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,14188,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,9896.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,10073.48,,,percent of total billed charges,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9931.6,,,percent of total billed charges,,,,,,8512.8,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12059.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10641,,,percent of total billed charges,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,14188,,,percent of total billed charges,,,,,,6384.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10641,,,percent of total billed charges,,,,,,7803.4,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,14188,,,fee schedule,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,14188,,,percent of total billed charges,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7803.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14188,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12059.8,,,percent of total billed charges,,,,,,10641,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 8 X 12 X 205,18851,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 8 X 12 X 205,18851,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 8 X 14 X 205,18852,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 8 X 14 X 205,18852,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 9 X 13 X 205,18853,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 9 X 13 X 205,18853,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 9 X 15 X 205,18854,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 9 X 15 X 205,18854,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 10 X 14 X 205,18855,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 10 X 14 X 205,18855,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 10 X 16 X 205,18856,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 10 X 16 X 205,18856,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 11 X 15 X 205,18857,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 11 X 15 X 205,18857,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 11 X 17 X 205,18858,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 11 X 17 X 205,18858,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 20 X 16 X 205,18859,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 20 X 16 X 205,18859,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 12 X 18 X 205,18860,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 12 X 18 X 205,18860,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 13 X 17 X 205,18861,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 13 X 17 X 205,18861,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 13 X 19 X 205,18862,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 13 X 19 X 205,18862,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 14 X 18 X 205,18863,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 14 X 18 X 205,18863,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR HIP RESTORATION HA 14 X 20 X 205,18864,CDM,0278,RC,,,,,,inpatient,facility,,,13433,13433,6044.85,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10746.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10074.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8120.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13433,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,8731.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR HIP RESTORATION HA 14 X 20 X 205,18864,CDM,0278,RC,,,,,,outpatient,facility,,,13433,13433,129.72,13433,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,11418.05,,,percent of total billed charges,,,,,,4029.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10074.75,,,percent of total billed charges,,,,,,9403.1,,,percent of total billed charges,,,,,,9403.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8731.45,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,13433,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,9369.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9537.43,,,percent of total billed charges,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9403.1,,,percent of total billed charges,,,,,,8059.8,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,11418.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13433,,,percent of total billed charges,,,,,,6044.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.75,,,percent of total billed charges,,,,,,7388.15,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13433,,,fee schedule,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,13433,,,percent of total billed charges,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7388.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13433,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11418.05,,,percent of total billed charges,,,,,,10074.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TIBIA DEP KNEE PFC SZ 2 NC,18926,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
TIBIA DEP KNEE PFC SZ 2 NC,18926,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TIBIA DEP KNEE PFC SZ 2.5 NC,18927,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
TIBIA DEP KNEE PFC SZ 2.5 NC,18927,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TIBIA DEP KNEE PFC SZ 3 NC,18928,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
TIBIA DEP KNEE PFC SZ 3 NC,18928,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TIBIA DEP KNEE PFC SZ 4 NC,18929,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
TIBIA DEP KNEE PFC SZ 4 NC,18929,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TIBIA DEP KNEE PFC SZ 5 NC,18930,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
TIBIA DEP KNEE PFC SZ 5 NC,18930,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TIBIA DEP KNEE PFC SZ 6 NC,18931,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
TIBIA DEP KNEE PFC SZ 6 NC,18931,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEMOSTAT SURGICEL STRL 2 X 3  i,190,CDM,0272,RC,,,,,,inpatient,facility,,,128.09,128.09,57.64,128.09,,,,,,,,,,,,,,,,,,,,108.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.66,,,percent of total billed charges,,,,,,76.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,128.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,57.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.88,,,percent of total billed charges,,,,,,,,,,,,,,
HEMOSTAT SURGICEL STRL 2 X 3  i,190,CDM,0272,RC,,,,,,outpatient,facility,,,128.09,128.09,24.34,1016,,83.26,,,percent of total billed charges,,,,,,,,,,,,,,,108.88,,,percent of total billed charges,,,,,,38.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,24.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,96.07,,,percent of total billed charges,,,,,,89.66,,,percent of total billed charges,,,,,,89.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,83.26,,,percent of total billed charges,,,,,,30.74,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",86.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,128.09,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,53.8,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",89.66,,,percent of total billed charges,,,,,,,,,,,,,,,128.09,,,percent of total billed charges,,,,,,89.34,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.66,,,percent of total billed charges,,,,,,76.85,,,percent of total billed charges,,,,,,57.64,,,percent of total billed charges,,,,,,,,,,,,,,,108.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,,percent of total billed charges,,,,,,128.09,,,percent of total billed charges,,,,,,55.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,128.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.07,,,percent of total billed charges,,,,,,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,128.09,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,128.09,,,percent of total billed charges,,,,,,57.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.09,,,fee schedule,,,,,,128.09,,,percent of total billed charges,,,,,,128.09,,,percent of total billed charges,,,,,,128.09,,,percent of total billed charges,,,,,,61.48,,,percent of total billed charges,,,,,,,,,,,,,,,75.57,,,percent of total billed charges,,,,,,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,128.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.88,,,percent of total billed charges,,,,,,96.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEMOSTAT SURGICEL STRL 2 X 14  i,191,CDM,0272,RC,,,,,,inpatient,facility,,,207.83,207.83,93.52,207.83,,,,,,,,,,,,,,,,,,,,176.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,145.48,,,percent of total billed charges,,,,,,124.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,176.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,207.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,93.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.66,,,percent of total billed charges,,,,,,,,,,,,,,
HEMOSTAT SURGICEL STRL 2 X 14  i,191,CDM,0272,RC,,,,,,outpatient,facility,,,207.83,207.83,39.49,1016,,135.09,,,percent of total billed charges,,,,,,,,,,,,,,,176.66,,,percent of total billed charges,,,,,,62.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,39.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,39.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,155.88,,,percent of total billed charges,,,,,,145.48,,,percent of total billed charges,,,,,,145.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,135.09,,,percent of total billed charges,,,,,,49.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",140.29,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,207.83,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",145.48,,,percent of total billed charges,,,,,,,,,,,,,,,207.83,,,percent of total billed charges,,,,,,144.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,147.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,145.48,,,percent of total billed charges,,,,,,124.7,,,percent of total billed charges,,,,,,93.52,,,percent of total billed charges,,,,,,,,,,,,,,,176.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.83,,,percent of total billed charges,,,,,,207.83,,,percent of total billed charges,,,,,,89.37,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,207.83,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,207.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.87,,,percent of total billed charges,,,,,,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,207.83,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,207.83,,,percent of total billed charges,,,,,,93.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.83,,,fee schedule,,,,,,207.83,,,percent of total billed charges,,,,,,207.83,,,percent of total billed charges,,,,,,207.83,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,122.62,,,percent of total billed charges,,,,,,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,207.83,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,176.66,,,percent of total billed charges,,,,,,155.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE IX WIZDOM STEER STRT SOFT .014 X 300,19109,CDM,0272,RC,,,,,,inpatient,facility,,,231.52,231.52,104.18,231.52,,,,,,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,162.06,,,percent of total billed charges,,,,,,138.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE IX WIZDOM STEER STRT SOFT .014 X 300,19109,CDM,0272,RC,,,,,,outpatient,facility,,,231.52,231.52,43.99,1016,,150.49,,,percent of total billed charges,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,69.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,108.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,43.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,173.64,,,percent of total billed charges,,,,,,162.06,,,percent of total billed charges,,,,,,162.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,150.49,,,percent of total billed charges,,,,,,55.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",156.28,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,231.52,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",162.06,,,percent of total billed charges,,,,,,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,161.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,164.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,162.06,,,percent of total billed charges,,,,,,138.91,,,percent of total billed charges,,,,,,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,231.52,,,percent of total billed charges,,,,,,99.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,231.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.64,,,percent of total billed charges,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,231.52,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,231.52,,,percent of total billed charges,,,,,,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,,fee schedule,,,,,,231.52,,,percent of total billed charges,,,,,,231.52,,,percent of total billed charges,,,,,,231.52,,,percent of total billed charges,,,,,,111.13,,,percent of total billed charges,,,,,,,,,,,,,,,136.6,,,percent of total billed charges,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.79,,,percent of total billed charges,,,,,,173.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE IX WIZDOM STEER STRT SOFT .014 X 180,19110,CDM,0272,RC,,,,,,inpatient,facility,,,231.52,231.52,104.18,231.52,,,,,,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,162.06,,,percent of total billed charges,,,,,,138.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE IX WIZDOM STEER STRT SOFT .014 X 180,19110,CDM,0272,RC,,,,,,outpatient,facility,,,231.52,231.52,43.99,1016,,150.49,,,percent of total billed charges,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,69.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,108.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,43.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,173.64,,,percent of total billed charges,,,,,,162.06,,,percent of total billed charges,,,,,,162.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,150.49,,,percent of total billed charges,,,,,,55.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",156.28,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,231.52,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",162.06,,,percent of total billed charges,,,,,,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,161.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,164.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,162.06,,,percent of total billed charges,,,,,,138.91,,,percent of total billed charges,,,,,,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,196.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,231.52,,,percent of total billed charges,,,,,,99.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,231.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.64,,,percent of total billed charges,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,231.52,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,231.52,,,percent of total billed charges,,,,,,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.52,,,fee schedule,,,,,,231.52,,,percent of total billed charges,,,,,,231.52,,,percent of total billed charges,,,,,,231.52,,,percent of total billed charges,,,,,,111.13,,,percent of total billed charges,,,,,,,,,,,,,,,136.6,,,percent of total billed charges,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,231.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.79,,,percent of total billed charges,,,,,,173.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TORQUE VICE .010 .038  i,19128,CDM,0272,RC,,,,,,inpatient,facility,,,20.79,20.79,9.36,20.79,,,,,,,,,,,,,,,,,,,,17.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.55,,,percent of total billed charges,,,,,,12.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,17.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,9.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.67,,,percent of total billed charges,,,,,,,,,,,,,,
TORQUE VICE .010 .038  i,19128,CDM,0272,RC,,,,,,outpatient,facility,,,20.79,20.79,3.95,1016,,13.51,,,percent of total billed charges,,,,,,,,,,,,,,,17.67,,,percent of total billed charges,,,,,,6.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,9.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,3.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,15.59,,,percent of total billed charges,,,,,,14.55,,,percent of total billed charges,,,,,,14.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,13.51,,,percent of total billed charges,,,,,,4.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",14.03,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,20.79,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,8.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",14.55,,,percent of total billed charges,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,14.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,14.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,14.55,,,percent of total billed charges,,,,,,12.47,,,percent of total billed charges,,,,,,9.36,,,percent of total billed charges,,,,,,,,,,,,,,,17.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,20.79,,,percent of total billed charges,,,,,,8.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,20.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.59,,,percent of total billed charges,,,,,,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,20.79,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,20.79,,,percent of total billed charges,,,,,,9.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.79,,,fee schedule,,,,,,20.79,,,percent of total billed charges,,,,,,20.79,,,percent of total billed charges,,,,,,20.79,,,percent of total billed charges,,,,,,9.98,,,percent of total billed charges,,,,,,,,,,,,,,,12.27,,,percent of total billed charges,,,,,,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,20.79,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,17.67,,,percent of total billed charges,,,,,,15.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH BALL RIGIFLEX ACHALASIA 30MM,19153,CDM,0272,RC,,,,,,inpatient,facility,,,2423.01,2423.01,1090.35,2423.01,,,,,,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1574.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1720.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1696.11,,,percent of total billed charges,,,,,,1453.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1090.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,,,,,,,,,
CATH BALL RIGIFLEX ACHALASIA 30MM,19153,CDM,0272,RC,,,,,,outpatient,facility,,,2423.01,2423.01,129.72,2423.01,,1574.96,,,percent of total billed charges,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,726.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1138.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,460.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,460.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1817.26,,,percent of total billed charges,,,,,,1696.11,,,percent of total billed charges,,,,,,1696.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1574.96,,,percent of total billed charges,,,,,,581.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1635.53,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2423.01,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1017.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1696.11,,,percent of total billed charges,,,,,,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,1690.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1720.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1696.11,,,percent of total billed charges,,,,,,1453.81,,,percent of total billed charges,,,,,,1090.35,,,percent of total billed charges,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,2423.01,,,percent of total billed charges,,,,,,1041.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2423.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.26,,,percent of total billed charges,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2423.01,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2423.01,,,percent of total billed charges,,,,,,1090.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,,fee schedule,,,,,,2423.01,,,percent of total billed charges,,,,,,2423.01,,,percent of total billed charges,,,,,,2423.01,,,percent of total billed charges,,,,,,1163.04,,,percent of total billed charges,,,,,,,,,,,,,,,1429.58,,,percent of total billed charges,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2059.56,,,percent of total billed charges,,,,,,1817.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH BALL RIGIFLEX ACHALASIA 35MM,19154,CDM,0272,RC,,,,,,inpatient,facility,,,2423.01,2423.01,1090.35,2423.01,,,,,,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1574.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1720.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1696.11,,,percent of total billed charges,,,,,,1453.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1090.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,,,,,,,,,
CATH BALL RIGIFLEX ACHALASIA 35MM,19154,CDM,0272,RC,,,,,,outpatient,facility,,,2423.01,2423.01,129.72,2423.01,,1574.96,,,percent of total billed charges,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,726.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1138.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,460.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,460.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1817.26,,,percent of total billed charges,,,,,,1696.11,,,percent of total billed charges,,,,,,1696.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1574.96,,,percent of total billed charges,,,,,,581.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1635.53,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2423.01,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1017.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1696.11,,,percent of total billed charges,,,,,,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,1690.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1720.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1696.11,,,percent of total billed charges,,,,,,1453.81,,,percent of total billed charges,,,,,,1090.35,,,percent of total billed charges,,,,,,,,,,,,,,,2059.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,2423.01,,,percent of total billed charges,,,,,,1041.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2423.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.26,,,percent of total billed charges,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2423.01,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2423.01,,,percent of total billed charges,,,,,,1090.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1817.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2423.01,,,fee schedule,,,,,,2423.01,,,percent of total billed charges,,,,,,2423.01,,,percent of total billed charges,,,,,,2423.01,,,percent of total billed charges,,,,,,1163.04,,,percent of total billed charges,,,,,,,,,,,,,,,1429.58,,,percent of total billed charges,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2423.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2059.56,,,percent of total billed charges,,,,,,1817.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH BILIARY SOEHENDRA 6.0FR 3 X 200,19182,CDM,0272,RC,,,,,,inpatient,facility,,,255.5,255.5,114.98,255.5,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,178.85,,,percent of total billed charges,,,,,,153.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,
CATH BILIARY SOEHENDRA 6.0FR 3 X 200,19182,CDM,0272,RC,,,,,,outpatient,facility,,,255.5,255.5,48.55,1016,,166.07,,,percent of total billed charges,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,76.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,48.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,191.62,,,percent of total billed charges,,,,,,178.85,,,percent of total billed charges,,,,,,178.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.08,,,percent of total billed charges,,,,,,61.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,255.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.31,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",178.85,,,percent of total billed charges,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,178.21,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,181.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,178.85,,,percent of total billed charges,,,,,,153.3,,,percent of total billed charges,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,109.86,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.62,,,percent of total billed charges,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,,percent of total billed charges,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,fee schedule,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,122.64,,,percent of total billed charges,,,,,,,,,,,,,,,150.75,,,percent of total billed charges,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,217.18,,,percent of total billed charges,,,,,,191.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH BILIARY SOEHENDRA 7.0FR 3 X 200,19185,CDM,0272,RC,,,,,,inpatient,facility,,,255.5,255.5,114.98,255.5,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,178.85,,,percent of total billed charges,,,,,,153.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,
CATH BILIARY SOEHENDRA 7.0FR 3 X 200,19185,CDM,0272,RC,,,,,,outpatient,facility,,,255.5,255.5,48.55,1016,,166.07,,,percent of total billed charges,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,76.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,48.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,191.62,,,percent of total billed charges,,,,,,178.85,,,percent of total billed charges,,,,,,178.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.08,,,percent of total billed charges,,,,,,61.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,255.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.31,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",178.85,,,percent of total billed charges,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,178.21,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,181.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,178.85,,,percent of total billed charges,,,,,,153.3,,,percent of total billed charges,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,109.86,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.62,,,percent of total billed charges,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,,percent of total billed charges,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,fee schedule,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,122.64,,,percent of total billed charges,,,,,,,,,,,,,,,150.75,,,percent of total billed charges,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,217.18,,,percent of total billed charges,,,,,,191.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEMOSTAT SURGICEL STRL 4 X 8  i,192,CDM,0272,RC,,,,,,inpatient,facility,,,219.61,219.61,98.82,219.61,,,,,,,,,,,,,,,,,,,,186.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,153.73,,,percent of total billed charges,,,,,,131.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,186.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,219.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,98.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.67,,,percent of total billed charges,,,,,,,,,,,,,,
HEMOSTAT SURGICEL STRL 4 X 8  i,192,CDM,0272,RC,,,,,,outpatient,facility,,,219.61,219.61,41.73,1016,,142.75,,,percent of total billed charges,,,,,,,,,,,,,,,186.67,,,percent of total billed charges,,,,,,65.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,164.71,,,percent of total billed charges,,,,,,153.73,,,percent of total billed charges,,,,,,153.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,142.75,,,percent of total billed charges,,,,,,52.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",148.24,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,219.61,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",153.73,,,percent of total billed charges,,,,,,,,,,,,,,,219.61,,,percent of total billed charges,,,,,,153.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,155.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,153.73,,,percent of total billed charges,,,,,,131.77,,,percent of total billed charges,,,,,,98.82,,,percent of total billed charges,,,,,,,,,,,,,,,186.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.61,,,percent of total billed charges,,,,,,219.61,,,percent of total billed charges,,,,,,94.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,219.61,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,219.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.71,,,percent of total billed charges,,,,,,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.61,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,219.61,,,percent of total billed charges,,,,,,98.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.61,,,fee schedule,,,,,,219.61,,,percent of total billed charges,,,,,,219.61,,,percent of total billed charges,,,,,,219.61,,,percent of total billed charges,,,,,,105.41,,,percent of total billed charges,,,,,,,,,,,,,,,129.57,,,percent of total billed charges,,,,,,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,219.61,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,186.67,,,percent of total billed charges,,,,,,164.71,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN RECON CRVD SS 6H 3.5 X 70,19216,CDM,0278,RC,,,,,,inpatient,facility,,,1367.4,1367.4,615.33,1367.4,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1162.29,,,percent of total billed charges,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1025.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,752.07,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,826.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",970.85,,,percent of total billed charges,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,957.18,,,percent of total billed charges,,,,,,820.44,,,percent of total billed charges,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1162.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.07,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1367.4,,,percent of total billed charges,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1025.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1367.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,615.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1162.29,,,percent of total billed charges,,,,,,888.81,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN RECON CRVD SS 6H 3.5 X 70,19216,CDM,0278,RC,,,,,,outpatient,facility,,,1367.4,1367.4,129.72,1367.4,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1162.29,,,percent of total billed charges,,,,,,410.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,259.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,259.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1025.55,,,percent of total billed charges,,,,,,957.18,,,percent of total billed charges,,,,,,957.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,888.81,,,percent of total billed charges,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1367.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,957.18,,,percent of total billed charges,,,,,,752.07,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1367.4,,,percent of total billed charges,,,,,,953.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,970.85,,,percent of total billed charges,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,957.18,,,percent of total billed charges,,,,,,820.44,,,percent of total billed charges,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1162.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,752.07,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1367.4,,,percent of total billed charges,,,,,,1367.4,,,percent of total billed charges,,,,,,752.07,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1367.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1367.4,,,percent of total billed charges,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1025.55,,,percent of total billed charges,,,,,,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1367.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1367.4,,,percent of total billed charges,,,,,,615.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1025.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1367.4,,,fee schedule,,,,,,1367.4,,,percent of total billed charges,,,,,,1367.4,,,percent of total billed charges,,,,,,1367.4,,,percent of total billed charges,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,752.07,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1367.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1162.29,,,percent of total billed charges,,,,,,1025.55,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN RECON CRVD SS 8H 3.5 X 94,19217,CDM,0278,RC,,,,,,inpatient,facility,,,1484.36,1484.36,667.96,1484.36,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1261.71,,,percent of total billed charges,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1187.49,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1113.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,816.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,897.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1053.9,,,percent of total billed charges,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.05,,,percent of total billed charges,,,,,,890.62,,,percent of total billed charges,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1261.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1484.36,,,percent of total billed charges,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1113.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1484.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,667.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1261.71,,,percent of total billed charges,,,,,,964.83,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN RECON CRVD SS 8H 3.5 X 94,19217,CDM,0278,RC,,,,,,outpatient,facility,,,1484.36,1484.36,129.72,1484.36,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1261.71,,,percent of total billed charges,,,,,,445.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,282.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,282.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1113.27,,,percent of total billed charges,,,,,,1039.05,,,percent of total billed charges,,,,,,1039.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,964.83,,,percent of total billed charges,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1484.36,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.05,,,percent of total billed charges,,,,,,816.4,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1484.36,,,percent of total billed charges,,,,,,1035.34,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1053.9,,,percent of total billed charges,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.05,,,percent of total billed charges,,,,,,890.62,,,percent of total billed charges,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1261.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,816.4,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1484.36,,,percent of total billed charges,,,,,,1484.36,,,percent of total billed charges,,,,,,816.4,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1484.36,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1484.36,,,percent of total billed charges,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1113.27,,,percent of total billed charges,,,,,,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1484.36,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1484.36,,,percent of total billed charges,,,,,,667.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1113.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1484.36,,,fee schedule,,,,,,1484.36,,,percent of total billed charges,,,,,,1484.36,,,percent of total billed charges,,,,,,1484.36,,,percent of total billed charges,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,816.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1484.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1261.71,,,percent of total billed charges,,,,,,1113.27,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN RECON CRVD SS 10H 3.5 X 118,19218,CDM,0278,RC,,,,,,inpatient,facility,,,1552.3,1552.3,698.53,1552.3,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1319.46,,,percent of total billed charges,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1241.84,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1164.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,853.77,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,938.37,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1102.13,,,percent of total billed charges,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1086.61,,,percent of total billed charges,,,,,,931.38,,,percent of total billed charges,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1319.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.77,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.3,,,percent of total billed charges,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1164.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1552.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,698.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1319.46,,,percent of total billed charges,,,,,,1009,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN RECON CRVD SS 10H 3.5 X 118,19218,CDM,0278,RC,,,,,,outpatient,facility,,,1552.3,1552.3,129.72,1552.3,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1319.46,,,percent of total billed charges,,,,,,465.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,294.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,294.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1164.22,,,percent of total billed charges,,,,,,1086.61,,,percent of total billed charges,,,,,,1086.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1009,,,percent of total billed charges,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1552.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1086.61,,,percent of total billed charges,,,,,,853.77,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1552.3,,,percent of total billed charges,,,,,,1082.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1102.13,,,percent of total billed charges,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1086.61,,,percent of total billed charges,,,,,,931.38,,,percent of total billed charges,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1319.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,853.77,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1552.3,,,percent of total billed charges,,,,,,1552.3,,,percent of total billed charges,,,,,,853.77,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1552.3,,,percent of total billed charges,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1164.22,,,percent of total billed charges,,,,,,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1552.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1552.3,,,percent of total billed charges,,,,,,698.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1552.3,,,fee schedule,,,,,,1552.3,,,percent of total billed charges,,,,,,1552.3,,,percent of total billed charges,,,,,,1552.3,,,percent of total billed charges,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,853.77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1552.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1319.46,,,percent of total billed charges,,,,,,1164.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DILATOR BALL ESOPH PYLORIC CRE 7.5FR 15 18 X 180,19257,CDM,0272,RC,,,,,,inpatient,facility,,,826.73,826.73,372.03,826.73,,,,,,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,586.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,578.71,,,percent of total billed charges,,,,,,496.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,372.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,,,,,,,,,
DILATOR BALL ESOPH PYLORIC CRE 7.5FR 15 18 X 180,19257,CDM,0272,RC,,,,,,outpatient,facility,,,826.73,826.73,129.72,1016,,537.37,,,percent of total billed charges,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,248.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,388.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,157.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,157.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,620.04,,,percent of total billed charges,,,,,,578.71,,,percent of total billed charges,,,,,,578.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,537.37,,,percent of total billed charges,,,,,,198.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",558.04,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,826.73,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,347.23,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",578.71,,,percent of total billed charges,,,,,,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,576.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,586.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,578.71,,,percent of total billed charges,,,,,,496.04,,,percent of total billed charges,,,,,,372.03,,,percent of total billed charges,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,826.73,,,percent of total billed charges,,,,,,355.49,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,826.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.05,,,percent of total billed charges,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,826.73,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.73,,,percent of total billed charges,,,,,,372.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,,fee schedule,,,,,,826.73,,,percent of total billed charges,,,,,,826.73,,,percent of total billed charges,,,,,,826.73,,,percent of total billed charges,,,,,,396.83,,,percent of total billed charges,,,,,,,,,,,,,,,487.77,,,percent of total billed charges,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,702.72,,,percent of total billed charges,,,,,,620.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FORCEP BX RADIAL JAW 4 COLD LRG CAP W NDL 240CM BX,19329,CDM,0272,RC,,,,,,inpatient,facility,,,35,35,15.75,35,,,,,,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,15.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,
FORCEP BX RADIAL JAW 4 COLD LRG CAP W NDL 240CM BX,19329,CDM,0272,RC,,,,,,outpatient,facility,,,35,35,6.65,1016,,22.75,,,percent of total billed charges,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,,,,,10.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,26.25,,,percent of total billed charges,,,,,,24.5,,,percent of total billed charges,,,,,,24.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,22.75,,,percent of total billed charges,,,,,,8.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",23.62,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,35,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,14.7,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",24.5,,,percent of total billed charges,,,,,,,,,,,,,,,35,,,percent of total billed charges,,,,,,24.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,24.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.5,,,percent of total billed charges,,,,,,21,,,percent of total billed charges,,,,,,15.75,,,percent of total billed charges,,,,,,,,,,,,,,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35,,,percent of total billed charges,,,,,,35,,,percent of total billed charges,,,,,,15.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,35,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.25,,,percent of total billed charges,,,,,,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,35,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,35,,,percent of total billed charges,,,,,,15.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35,,,fee schedule,,,,,,35,,,percent of total billed charges,,,,,,35,,,percent of total billed charges,,,,,,35,,,percent of total billed charges,,,,,,16.8,,,percent of total billed charges,,,,,,,,,,,,,,,20.65,,,percent of total billed charges,,,,,,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.75,,,percent of total billed charges,,,,,,26.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEAD MED CAPSUREFIX NOVUS 45CM 4076,19341,CDM,0275,RC,,,,,,inpatient,facility,,,850,850,382.5,850,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,
LEAD MED CAPSUREFIX NOVUS 45CM 4076,19341,CDM,0275,RC,,,,,,outpatient,facility,,,850,850,129.72,850,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,255,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637.5,,,percent of total billed charges,,,,,,595,,,percent of total billed charges,,,,,,595,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,850,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,592.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,850,,,fee schedule,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,722.5,,,percent of total billed charges,,,,,,637.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE ZIM PLAIN STRL.028,19478,CDM,0272,RC,,,,,,inpatient,facility,,,46.86,46.86,21.09,46.86,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.8,,,percent of total billed charges,,,,,,28.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE ZIM PLAIN STRL.028,19478,CDM,0272,RC,,,,,,outpatient,facility,,,46.86,46.86,8.9,1016,,30.46,,,percent of total billed charges,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,14.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.14,,,percent of total billed charges,,,,,,32.8,,,percent of total billed charges,,,,,,32.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.46,,,percent of total billed charges,,,,,,11.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",31.63,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.86,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.68,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.8,,,percent of total billed charges,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,32.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.8,,,percent of total billed charges,,,,,,28.12,,,percent of total billed charges,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,39.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,20.15,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.86,,,percent of total billed charges,,,,,,21.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.86,,,fee schedule,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,46.86,,,percent of total billed charges,,,,,,22.49,,,percent of total billed charges,,,,,,,,,,,,,,,27.65,,,percent of total billed charges,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.86,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.83,,,percent of total billed charges,,,,,,35.15,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP TRIDENT C TAPER LFIT COCR 28   2.5 NC,19532,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP TRIDENT C TAPER LFIT COCR 28   2.5 NC,19532,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP TRIDENT C TAPER LFIT COCR 28   0 NC,19533,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP TRIDENT C TAPER LFIT COCR 28   0 NC,19533,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP TRIDENT C TAPER LFIT COCR 28   5 NC,19534,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP TRIDENT C TAPER LFIT COCR 28   5 NC,19534,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP TRIDENT C TAPER LFIT COCR 28   10 NC,19535,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP TRIDENT C TAPER LFIT COCR 28   10 NC,19535,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP MORSE TAPER LFIT 28   0 NC,19536,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP MORSE TAPER LFIT 28   0 NC,19536,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP MORSE TAPER LFIT 28   5 NC,19537,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP MORSE TAPER LFIT 28   5 NC,19537,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP MORSE TAPER LFIT 28   10 NC,19538,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP MORSE TAPER LFIT 28   10 NC,19538,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP STR HIP INS OMNIFIT II 10DG 28 X 46,19539,CDM,0278,RC,,,,,,inpatient,facility,,,1827.1,1827.1,822.19,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1461.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1370.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1104.48,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,1187.62,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP STR HIP INS OMNIFIT II 10DG 28 X 46,19539,CDM,0278,RC,,,,,,outpatient,facility,,,1827.1,1827.1,129.72,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,548.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1370.32,,,percent of total billed charges,,,,,,1278.97,,,percent of total billed charges,,,,,,1278.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1187.62,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1827.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1274.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,,percent of total billed charges,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1827.1,,,fee schedule,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1553.04,,,percent of total billed charges,,,,,,1370.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP STR HIP INS OMNIFIT II 10DG 28 X 50,19540,CDM,0278,RC,,,,,,inpatient,facility,,,1827.1,1827.1,822.19,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1461.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1370.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1104.48,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,1187.62,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP STR HIP INS OMNIFIT II 10DG 28 X 50,19540,CDM,0278,RC,,,,,,outpatient,facility,,,1827.1,1827.1,129.72,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,548.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1370.32,,,percent of total billed charges,,,,,,1278.97,,,percent of total billed charges,,,,,,1278.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1187.62,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1827.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1274.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,,percent of total billed charges,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1827.1,,,fee schedule,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1553.04,,,percent of total billed charges,,,,,,1370.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP STR HIP INS OMNIFIT II 10DG 28 X 54,19541,CDM,0278,RC,,,,,,inpatient,facility,,,1827.1,1827.1,822.19,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1461.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1370.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1104.48,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,1187.62,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP STR HIP INS OMNIFIT II 10DG 28 X 54,19541,CDM,0278,RC,,,,,,outpatient,facility,,,1827.1,1827.1,129.72,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,548.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1370.32,,,percent of total billed charges,,,,,,1278.97,,,percent of total billed charges,,,,,,1278.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1187.62,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1827.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1274.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,,percent of total billed charges,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1827.1,,,fee schedule,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1553.04,,,percent of total billed charges,,,,,,1370.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP STR HIP INS OMNIFIT II 10DG 28 X 58,19542,CDM,0278,RC,,,,,,inpatient,facility,,,1827.1,1827.1,822.19,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1461.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1370.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1104.48,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,1187.62,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP STR HIP INS OMNIFIT II 10DG 28 X 58,19542,CDM,0278,RC,,,,,,outpatient,facility,,,1827.1,1827.1,129.72,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,548.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1370.32,,,percent of total billed charges,,,,,,1278.97,,,percent of total billed charges,,,,,,1278.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1187.62,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1827.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1274.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,,percent of total billed charges,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1827.1,,,fee schedule,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1553.04,,,percent of total billed charges,,,,,,1370.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP STR HIP INS OMNIFIT II 10DG 28 X 62,19543,CDM,0278,RC,,,,,,inpatient,facility,,,1827.1,1827.1,822.19,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1461.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1370.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1104.48,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,1187.62,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP STR HIP INS OMNIFIT II 10DG 28 X 62,19543,CDM,0278,RC,,,,,,outpatient,facility,,,1827.1,1827.1,129.72,1827.1,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1553.04,,,percent of total billed charges,,,,,,548.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,347.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1370.32,,,percent of total billed charges,,,,,,1278.97,,,percent of total billed charges,,,,,,1278.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1187.62,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1827.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1004.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1274.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1297.24,,,percent of total billed charges,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.97,,,percent of total billed charges,,,,,,1096.26,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1553.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1827.1,,,percent of total billed charges,,,,,,822.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1370.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1827.1,,,fee schedule,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1827.1,,,percent of total billed charges,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1004.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1827.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1553.04,,,percent of total billed charges,,,,,,1370.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KIT ACL DISP  i,19565,CDM,0272,RC,,,,,,inpatient,facility,,,826.87,826.87,372.09,826.87,,,,,,,,,,,,,,,,,,,,702.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,587.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,578.81,,,percent of total billed charges,,,,,,496.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,702.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,826.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,372.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,702.84,,,percent of total billed charges,,,,,,,,,,,,,,
KIT ACL DISP  i,19565,CDM,0272,RC,,,,,,outpatient,facility,,,826.87,826.87,129.72,1016,,537.47,,,percent of total billed charges,,,,,,,,,,,,,,,702.84,,,percent of total billed charges,,,,,,248.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,388.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,157.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,157.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,620.16,,,percent of total billed charges,,,,,,578.81,,,percent of total billed charges,,,,,,578.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,537.47,,,percent of total billed charges,,,,,,198.45,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",558.14,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,826.87,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,347.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",578.81,,,percent of total billed charges,,,,,,,,,,,,,,,826.87,,,percent of total billed charges,,,,,,576.74,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,587.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,578.81,,,percent of total billed charges,,,,,,496.12,,,percent of total billed charges,,,,,,372.09,,,percent of total billed charges,,,,,,,,,,,,,,,702.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.87,,,percent of total billed charges,,,,,,826.87,,,percent of total billed charges,,,,,,355.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,826.87,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,826.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.15,,,percent of total billed charges,,,,,,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,826.87,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.87,,,percent of total billed charges,,,,,,372.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.87,,,fee schedule,,,,,,826.87,,,percent of total billed charges,,,,,,826.87,,,percent of total billed charges,,,,,,826.87,,,percent of total billed charges,,,,,,396.9,,,percent of total billed charges,,,,,,,,,,,,,,,487.85,,,percent of total billed charges,,,,,,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,826.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,702.84,,,percent of total billed charges,,,,,,620.15,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STENT SET BILIARY ZIMMON 7.0FR 7CM,19665,CDM,0278,RC,,,,,,inpatient,facility,,,258,258,116.1,258,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,193.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,167.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STENT SET BILIARY ZIMMON 7.0FR 7CM,19665,CDM,0278,RC,,,,,,outpatient,facility,,,258,258,49.02,258,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,77.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,121.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,,percent of total billed charges,,,,,,180.6,,,percent of total billed charges,,,,,,180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,61.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",180.6,,,percent of total billed charges,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,179.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,110.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,fee schedule,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.3,,,percent of total billed charges,,,,,,193.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD STR XIA UNION OSS TI 40MM,19767,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD STR XIA UNION OSS TI 40MM,19767,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD STR XIA UNION OSS TI 60MM,19769,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD STR XIA UNION OSS TI 60MM,19769,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD STR XIA UNION OSS TI 70MM,19770,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD STR XIA UNION OSS TI 70MM,19770,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD STR XIA UNION OSS TI 80MM,19771,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD STR XIA UNION OSS TI 80MM,19771,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD STR XIA UNION OSS TI 90MM,19772,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD STR XIA UNION OSS TI 90MM,19772,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD STR XIA UNION OSS TI 120MM,19775,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD STR XIA UNION OSS TI 120MM,19775,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 44 NC,19791,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 44 NC,19791,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 45 NC,19792,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 45 NC,19792,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 46 NC,19793,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 46 NC,19793,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 48 NC,19796,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 48 NC,19796,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 49 NC,19797,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 49 NC,19797,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 50 NC,19798,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 50 NC,19798,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 51 NC,19799,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 51 NC,19799,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 52 NC,19800,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 52 NC,19800,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 53 NC,19801,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 53 NC,19801,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 54 NC,19802,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 54 NC,19802,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 55 NC,19803,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 55 NC,19803,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 56 NC,19804,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 56 NC,19804,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 58 NC,19805,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 58 NC,19805,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 61 NC,19806,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 61 NC,19806,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 64 NC,19807,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 64 NC,19807,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 68 NC,19808,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 68 NC,19808,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP UHR BIPOLAR 28 X 72 NC,19809,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP UHR BIPOLAR 28 X 72 NC,19809,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 28   0 NC,19810,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 28   0 NC,19810,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 28   5 NC,19811,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 28   5 NC,19811,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 28   10 NC,19812,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 28   10 NC,19812,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH BILIARY SOEHENDRA 8.5FR 3 X 200,19904,CDM,0272,RC,,,,,,inpatient,facility,,,255.5,255.5,114.98,255.5,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,178.85,,,percent of total billed charges,,,,,,153.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,
CATH BILIARY SOEHENDRA 8.5FR 3 X 200,19904,CDM,0272,RC,,,,,,outpatient,facility,,,255.5,255.5,48.55,1016,,166.07,,,percent of total billed charges,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,76.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,48.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,191.62,,,percent of total billed charges,,,,,,178.85,,,percent of total billed charges,,,,,,178.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.08,,,percent of total billed charges,,,,,,61.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,255.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.31,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",178.85,,,percent of total billed charges,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,178.21,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,181.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,178.85,,,percent of total billed charges,,,,,,153.3,,,percent of total billed charges,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,217.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,109.86,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.62,,,percent of total billed charges,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,255.5,,,percent of total billed charges,,,,,,114.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.5,,,fee schedule,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,255.5,,,percent of total billed charges,,,,,,122.64,,,percent of total billed charges,,,,,,,,,,,,,,,150.75,,,percent of total billed charges,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,255.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,217.18,,,percent of total billed charges,,,,,,191.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH BALL ESOPH PYLORIC COLONIC 7.5FR 10 12 X 240,19917,CDM,0272,RC,,,,,,inpatient,facility,,,826.73,826.73,372.03,826.73,,,,,,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,586.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,578.71,,,percent of total billed charges,,,,,,496.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,372.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,,,,,,,,,
CATH BALL ESOPH PYLORIC COLONIC 7.5FR 10 12 X 240,19917,CDM,0272,RC,,,,,,outpatient,facility,,,826.73,826.73,129.72,1016,,537.37,,,percent of total billed charges,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,248.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,388.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,157.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,157.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,620.04,,,percent of total billed charges,,,,,,578.71,,,percent of total billed charges,,,,,,578.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,537.37,,,percent of total billed charges,,,,,,198.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",558.04,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,826.73,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,347.23,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",578.71,,,percent of total billed charges,,,,,,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,576.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,586.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,578.71,,,percent of total billed charges,,,,,,496.04,,,percent of total billed charges,,,,,,372.03,,,percent of total billed charges,,,,,,,,,,,,,,,702.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,826.73,,,percent of total billed charges,,,,,,355.49,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,826.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.05,,,percent of total billed charges,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,826.73,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,826.73,,,percent of total billed charges,,,,,,372.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,620.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.73,,,fee schedule,,,,,,826.73,,,percent of total billed charges,,,,,,826.73,,,percent of total billed charges,,,,,,826.73,,,percent of total billed charges,,,,,,396.83,,,percent of total billed charges,,,,,,,,,,,,,,,487.77,,,percent of total billed charges,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,826.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,702.72,,,percent of total billed charges,,,,,,620.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
VALVE RESERVOIR RICKHAM 9.5M  i,20079,CDM,0278,RC,,,,,,inpatient,facility,,,978.08,978.08,440.14,978.08,,,,,,,,,,,,,,,,,,,,831.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,782.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,733.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,537.94,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,591.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",694.44,,,percent of total billed charges,,,,,,,,,,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,684.66,,,percent of total billed charges,,,,,,586.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,831.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.94,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,537.94,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.08,,,percent of total billed charges,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,733.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,978.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,440.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,831.37,,,percent of total billed charges,,,,,,635.75,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
VALVE RESERVOIR RICKHAM 9.5M  i,20079,CDM,0278,RC,,,,,,outpatient,facility,,,978.08,978.08,129.72,978.08,,635.75,,,percent of total billed charges,,,,,,,,,,,,,,,831.37,,,percent of total billed charges,,,,,,293.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,459.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,185.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,733.56,,,percent of total billed charges,,,,,,684.66,,,percent of total billed charges,,,,,,684.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,635.75,,,percent of total billed charges,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,978.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,684.66,,,percent of total billed charges,,,,,,537.94,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,978.08,,,percent of total billed charges,,,,,,682.21,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,694.44,,,percent of total billed charges,,,,,,,,,,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,684.66,,,percent of total billed charges,,,,,,586.85,,,percent of total billed charges,,,,,,440.14,,,percent of total billed charges,,,,,,,,,,,,,,,831.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.94,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,978.08,,,percent of total billed charges,,,,,,978.08,,,percent of total billed charges,,,,,,537.94,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,978.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,978.08,,,percent of total billed charges,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,733.56,,,percent of total billed charges,,,,,,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,978.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,978.08,,,percent of total billed charges,,,,,,440.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,733.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,537.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,978.08,,,fee schedule,,,,,,978.08,,,percent of total billed charges,,,,,,978.08,,,percent of total billed charges,,,,,,978.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,978.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,831.37,,,percent of total billed charges,,,,,,733.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STENT URET CONTOUR 7.0FR 24CM  i,20138,CDM,0278,RC,,,,,,inpatient,facility,,,215.46,215.46,96.96,215.46,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.37,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,161.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.82,,,percent of total billed charges,,,,,,129.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,140.05,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STENT URET CONTOUR 7.0FR 24CM  i,20138,CDM,0278,RC,,,,,,outpatient,facility,,,215.46,215.46,40.94,215.46,,140.05,,,percent of total billed charges,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,64.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,101.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,40.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.6,,,percent of total billed charges,,,,,,150.82,,,percent of total billed charges,,,,,,150.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,140.05,,,percent of total billed charges,,,,,,51.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,215.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,90.49,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",150.82,,,percent of total billed charges,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,150.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.82,,,percent of total billed charges,,,,,,129.28,,,percent of total billed charges,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,92.65,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.6,,,percent of total billed charges,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,,percent of total billed charges,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,fee schedule,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,183.14,,,percent of total billed charges,,,,,,161.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STENT URET CONTOUR 7.0FR 26CM  i,20139,CDM,0278,RC,,,,,,inpatient,facility,,,215.46,215.46,96.96,215.46,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.37,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,161.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.82,,,percent of total billed charges,,,,,,129.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,140.05,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STENT URET CONTOUR 7.0FR 26CM  i,20139,CDM,0278,RC,,,,,,outpatient,facility,,,215.46,215.46,40.94,215.46,,140.05,,,percent of total billed charges,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,64.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,101.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,40.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.6,,,percent of total billed charges,,,,,,150.82,,,percent of total billed charges,,,,,,150.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,140.05,,,percent of total billed charges,,,,,,51.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,215.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,90.49,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",150.82,,,percent of total billed charges,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,150.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.82,,,percent of total billed charges,,,,,,129.28,,,percent of total billed charges,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,92.65,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.6,,,percent of total billed charges,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,,percent of total billed charges,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,fee schedule,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,183.14,,,percent of total billed charges,,,,,,161.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 28,20140,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 28,20140,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 30,20141,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 30,20141,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 32,20142,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 32,20142,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 34,20143,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 34,20143,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 36,20144,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 36,20144,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 38,20145,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 38,20145,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 40,20146,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 40,20146,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 42,20147,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 42,20147,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 44,20148,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 44,20148,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 46,20149,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 46,20149,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 48,20150,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 48,20150,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 50,20151,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 50,20151,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 52,20152,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 52,20152,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 54,20153,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 54,20153,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC INTENSIVE CARE IN RECOVERY,20190008,CDM,0201,RC,,,,,,inpatient,facility,,,4820.4,4820.4,295.98,13000,,4217,,,per diem,,,,,,4820.4,,,fee schedule,,,,,,4097.34,,,percent of total billed charges,,,,,,,,,,,,,,,2398,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4820.4,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4820.4,,,case rate,,,,,,4820.4,,,case rate,,,,,,4820.4,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4820.4,,,case rate,,,,,,1960,,,per diem,,,,,,1750,,,per diem,,,,,,3374.28,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2410.2,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2410.2,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3133.26,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4820.4,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,3374.28,,,percent of total billed charges,,,,,,,,,,,,,,,4820.4,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3422.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3374.28,,,percent of total billed charges,,,,,,2892.24,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,4097.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4820.4,,,percent of total billed charges,,,,,,4820.4,,,percent of total billed charges,,,,,,1930,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2892.24,,,percent of total billed charges,,,,,,4820.4,,,fee schedule,,,,,,4820.4,,,fee schedule,,,,,,4820.4,,,fee schedule,,,,,,4820.4,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4820.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3615.3,,,percent of total billed charges,,,,,,4820.4,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4820.4,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4820.4,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4820.4,,,percent of total billed charges,,,,,,,,,,,,,,,4820.4,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4820.4,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4820.4,,,percent of total billed charges,,,,,,2169.18,,,percent of total billed charges,,,,,,,,,,,,,,,4820.4,,,fee schedule,,,,,,,,,,,,,,,4820.4,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4820.4,,,fee schedule,,,,,,,,,,,,,,,4820.4,,,fee schedule,,,,,,,,,,,,,,,2892.24,,,percent of total billed charges,,,,,,4820.4,,,percent of total billed charges,,,,,,2892.24,,,percent of total billed charges,,,,,,4669,,,per diem,,,,,,,,,,,,,,,7752,,,per diem,,,,,,4820.4,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4820.4,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,4097.34,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC INTENSIVE CARE,20190013,CDM,0201,RC,,,,,,inpatient,facility,,,6628.05,6628.05,295.98,13000,,4217,,,per diem,,,,,,6628.05,,,fee schedule,,,,,,5633.84,,,percent of total billed charges,,,,,,,,,,,,,,,2398,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,48898.86,21495.89,174710.99,16,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6628.05,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,6628.05,,,case rate,,,,,,6628.05,,,case rate,,,,,,6628.05,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,6628.05,,,case rate,,,,,,1960,,,per diem,,,,,,1750,,,per diem,,,,,,4639.64,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3314.03,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3314.03,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,4308.23,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,6628.05,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3834,,,per diem,,,,,,4639.64,,,percent of total billed charges,,,,,,,,,,,,,,,6628.05,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",4705.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4639.64,,,percent of total billed charges,,,,,,3976.83,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,5633.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6628.05,,,percent of total billed charges,,,,,,6628.05,,,percent of total billed charges,,,,,,1930,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3976.83,,,percent of total billed charges,,,,,,6628.05,,,fee schedule,,,,,,6628.05,,,fee schedule,,,,,,6628.05,,,fee schedule,,,,,,6628.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,6628.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4971.04,,,percent of total billed charges,,,,,,6628.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6628.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6628.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,6628.05,,,percent of total billed charges,,,,,,,,,,,,,,,6628.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6628.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6628.05,,,percent of total billed charges,,,,,,2982.62,,,percent of total billed charges,,,,,,,,,,,,,,,6628.05,,,fee schedule,,,,,,,,,,,,,,,6628.05,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,6628.05,,,fee schedule,,,,,,,,,,,,,,,6628.05,,,fee schedule,,,,,,,,,,,,,,,3976.83,,,percent of total billed charges,,,,,,6628.05,,,percent of total billed charges,,,,,,3976.83,,,percent of total billed charges,,,,,,4669,,,per diem,,,,,,,,,,,,,,,7752,,,per diem,,,,,,6628.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6628.05,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,5633.84,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
GRAFT PATCH VASCUGUARD BOVINE 1 X 6  i,20256,CDM,0278,RC,,,,,,inpatient,facility,,,441.1,441.1,198.5,441.1,,,,,,,,,,,,,,,,,,,,374.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.88,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,330.83,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.64,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",313.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,308.77,,,percent of total billed charges,,,,,,264.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,374.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,441.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,198.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.94,,,percent of total billed charges,,,,,,286.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT PATCH VASCUGUARD BOVINE 1 X 6  i,20256,CDM,0278,RC,,,,,,outpatient,facility,,,441.1,441.1,83.81,441.1,,286.71,,,percent of total billed charges,,,,,,,,,,,,,,,374.94,,,percent of total billed charges,,,,,,132.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,207.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,242.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,242.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,242.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,330.82,,,percent of total billed charges,,,,,,308.77,,,percent of total billed charges,,,,,,308.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,286.72,,,percent of total billed charges,,,,,,105.86,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,441.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,185.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",308.77,,,percent of total billed charges,,,,,,,,,,,,,,,441.1,,,percent of total billed charges,,,,,,307.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,313.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,308.77,,,percent of total billed charges,,,,,,264.66,,,percent of total billed charges,,,,,,198.5,,,percent of total billed charges,,,,,,,,,,,,,,,374.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.1,,,percent of total billed charges,,,,,,441.1,,,percent of total billed charges,,,,,,189.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,441.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,441.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.83,,,percent of total billed charges,,,,,,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,441.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,441.1,,,percent of total billed charges,,,,,,198.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,330.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.1,,,fee schedule,,,,,,441.1,,,percent of total billed charges,,,,,,441.1,,,percent of total billed charges,,,,,,441.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,441.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,374.94,,,percent of total billed charges,,,,,,330.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT PATCH VASCUGUARD BOVINE 2 X 9  i,20257,CDM,0278,RC,,,,,,inpatient,facility,,,694.54,694.54,312.54,694.54,,,,,,,,,,,,,,,,,,,,590.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.63,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,520.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.85,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",493.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,486.18,,,percent of total billed charges,,,,,,416.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,590.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,382,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,694.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,694.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,312.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.36,,,percent of total billed charges,,,,,,451.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT PATCH VASCUGUARD BOVINE 2 X 9  i,20257,CDM,0278,RC,,,,,,outpatient,facility,,,694.54,694.54,129.72,694.54,,451.45,,,percent of total billed charges,,,,,,,,,,,,,,,590.36,,,percent of total billed charges,,,,,,208.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,326.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,131.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,131.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,382,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,382,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,382,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,520.9,,,percent of total billed charges,,,,,,486.18,,,percent of total billed charges,,,,,,486.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,451.45,,,percent of total billed charges,,,,,,382,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,694.54,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,291.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",486.18,,,percent of total billed charges,,,,,,,,,,,,,,,694.54,,,percent of total billed charges,,,,,,484.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,493.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,486.18,,,percent of total billed charges,,,,,,416.72,,,percent of total billed charges,,,,,,312.54,,,percent of total billed charges,,,,,,,,,,,,,,,590.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,694.54,,,percent of total billed charges,,,,,,694.54,,,percent of total billed charges,,,,,,382,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,694.54,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,694.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.9,,,percent of total billed charges,,,,,,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,694.54,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,694.54,,,percent of total billed charges,,,,,,312.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,694.54,,,fee schedule,,,,,,694.54,,,percent of total billed charges,,,,,,694.54,,,percent of total billed charges,,,,,,694.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,694.54,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,590.36,,,percent of total billed charges,,,,,,520.9,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DERMACARRIER MESH GRAFTER 8 X 4  i,20395,CDM,0272,RC,,,,,,inpatient,facility,,,93.53,93.53,42.09,93.53,,,,,,,,,,,,,,,,,,,,79.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.47,,,percent of total billed charges,,,,,,56.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,79.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,93.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,42.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.5,,,percent of total billed charges,,,,,,,,,,,,,,
DERMACARRIER MESH GRAFTER 8 X 4  i,20395,CDM,0272,RC,,,,,,outpatient,facility,,,93.53,93.53,17.77,1016,,60.79,,,percent of total billed charges,,,,,,,,,,,,,,,79.5,,,percent of total billed charges,,,,,,28.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,17.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,70.14,,,percent of total billed charges,,,,,,65.47,,,percent of total billed charges,,,,,,65.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,60.79,,,percent of total billed charges,,,,,,22.45,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",63.13,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,93.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",65.47,,,percent of total billed charges,,,,,,,,,,,,,,,93.53,,,percent of total billed charges,,,,,,65.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,66.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.47,,,percent of total billed charges,,,,,,56.12,,,percent of total billed charges,,,,,,42.09,,,percent of total billed charges,,,,,,,,,,,,,,,79.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.53,,,percent of total billed charges,,,,,,93.53,,,percent of total billed charges,,,,,,40.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,93.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,93.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.15,,,percent of total billed charges,,,,,,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.53,,,percent of total billed charges,,,,,,42.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.53,,,fee schedule,,,,,,93.53,,,percent of total billed charges,,,,,,93.53,,,percent of total billed charges,,,,,,93.53,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,55.18,,,percent of total billed charges,,,,,,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,93.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,79.5,,,percent of total billed charges,,,,,,70.15,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DERMACARRIER MESH GRAFTER 16 X 4  i,20396,CDM,0272,RC,,,,,,inpatient,facility,,,104.18,104.18,46.88,104.18,,,,,,,,,,,,,,,,,,,,88.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,72.93,,,percent of total billed charges,,,,,,62.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,88.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.55,,,percent of total billed charges,,,,,,,,,,,,,,
DERMACARRIER MESH GRAFTER 16 X 4  i,20396,CDM,0272,RC,,,,,,outpatient,facility,,,104.18,104.18,19.79,1016,,67.72,,,percent of total billed charges,,,,,,,,,,,,,,,88.55,,,percent of total billed charges,,,,,,31.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,19.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,19.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,78.13,,,percent of total billed charges,,,,,,72.93,,,percent of total billed charges,,,,,,72.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,67.72,,,percent of total billed charges,,,,,,25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",70.32,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,104.18,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,43.76,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",72.93,,,percent of total billed charges,,,,,,,,,,,,,,,104.18,,,percent of total billed charges,,,,,,72.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,73.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,72.93,,,percent of total billed charges,,,,,,62.51,,,percent of total billed charges,,,,,,46.88,,,percent of total billed charges,,,,,,,,,,,,,,,88.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.18,,,percent of total billed charges,,,,,,104.18,,,percent of total billed charges,,,,,,44.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,104.18,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,104.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.14,,,percent of total billed charges,,,,,,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,104.18,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104.18,,,percent of total billed charges,,,,,,46.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.18,,,fee schedule,,,,,,104.18,,,percent of total billed charges,,,,,,104.18,,,percent of total billed charges,,,,,,104.18,,,percent of total billed charges,,,,,,50.01,,,percent of total billed charges,,,,,,,,,,,,,,,61.47,,,percent of total billed charges,,,,,,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,104.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,88.55,,,percent of total billed charges,,,,,,78.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STENT SET BILIARY COTTON LEUNG 7.0FR 9CM,20405,CDM,0278,RC,,,,,,inpatient,facility,,,258,258,116.1,258,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,193.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,167.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STENT SET BILIARY COTTON LEUNG 7.0FR 9CM,20405,CDM,0278,RC,,,,,,outpatient,facility,,,258,258,49.02,258,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,77.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,121.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,,percent of total billed charges,,,,,,180.6,,,percent of total billed charges,,,,,,180.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,61.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",180.6,,,percent of total billed charges,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,179.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,110.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,258,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,fee schedule,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.3,,,percent of total billed charges,,,,,,193.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SNARE AMPLTZ GOOSE NECK 15 X 120,20412,CDM,0272,RC,,,,,,inpatient,facility,,,787.5,787.5,354.38,787.5,,,,,,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,559.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,551.25,,,percent of total billed charges,,,,,,472.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,,,,,,,,,
SNARE AMPLTZ GOOSE NECK 15 X 120,20412,CDM,0272,RC,,,,,,outpatient,facility,,,787.5,787.5,129.72,1016,,511.88,,,percent of total billed charges,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,236.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,370.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,149.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,149.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,590.62,,,percent of total billed charges,,,,,,551.25,,,percent of total billed charges,,,,,,551.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,511.88,,,percent of total billed charges,,,,,,189,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",531.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,787.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,330.75,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",551.25,,,percent of total billed charges,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,549.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,559.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,551.25,,,percent of total billed charges,,,,,,472.5,,,percent of total billed charges,,,,,,354.38,,,percent of total billed charges,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,787.5,,,percent of total billed charges,,,,,,338.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.62,,,percent of total billed charges,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,787.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.5,,,percent of total billed charges,,,,,,354.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,fee schedule,,,,,,787.5,,,percent of total billed charges,,,,,,787.5,,,percent of total billed charges,,,,,,787.5,,,percent of total billed charges,,,,,,378,,,percent of total billed charges,,,,,,,,,,,,,,,464.63,,,percent of total billed charges,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,669.38,,,percent of total billed charges,,,,,,590.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SET COLON DECOMPRESSION MARCON 7FR,20432,CDM,0272,RC,,,,,,inpatient,facility,,,535.5,535.5,240.97,535.5,,,,,,,,,,,,,,,,,,,,455.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,374.85,,,percent of total billed charges,,,,,,321.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,455.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,535.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,535.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,240.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455.18,,,percent of total billed charges,,,,,,,,,,,,,,
SET COLON DECOMPRESSION MARCON 7FR,20432,CDM,0272,RC,,,,,,outpatient,facility,,,535.5,535.5,101.75,1016,,348.07,,,percent of total billed charges,,,,,,,,,,,,,,,455.18,,,percent of total billed charges,,,,,,160.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,251.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,101.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,101.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,401.62,,,percent of total billed charges,,,,,,374.85,,,percent of total billed charges,,,,,,374.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,348.07,,,percent of total billed charges,,,,,,128.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",361.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,535.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.91,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",374.85,,,percent of total billed charges,,,,,,,,,,,,,,,535.5,,,percent of total billed charges,,,,,,373.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,380.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,374.85,,,percent of total billed charges,,,,,,321.3,,,percent of total billed charges,,,,,,240.97,,,percent of total billed charges,,,,,,,,,,,,,,,455.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,535.5,,,percent of total billed charges,,,,,,535.5,,,percent of total billed charges,,,,,,230.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,535.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,535.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.62,,,percent of total billed charges,,,,,,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,535.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,535.5,,,percent of total billed charges,,,,,,240.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,535.5,,,fee schedule,,,,,,535.5,,,percent of total billed charges,,,,,,535.5,,,percent of total billed charges,,,,,,535.5,,,percent of total billed charges,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,315.94,,,percent of total billed charges,,,,,,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,535.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,455.18,,,percent of total billed charges,,,,,,401.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEAD MED EPICARDIAL 53CM 5071,20493,CDM,0275,RC,,,,,,inpatient,facility,,,850,850,382.5,850,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,
LEAD MED EPICARDIAL 53CM 5071,20493,CDM,0275,RC,,,,,,outpatient,facility,,,850,850,129.72,850,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,255,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637.5,,,percent of total billed charges,,,,,,595,,,percent of total billed charges,,,,,,595,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,850,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,592.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,850,,,fee schedule,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,722.5,,,percent of total billed charges,,,,,,637.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
RESTRICTOR DEP CEMENT FEM SZ4,20534,CDM,0278,RC,,,,,,inpatient,facility,,,120.4,120.4,54.18,120.4,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,90.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.78,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",85.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.28,,,percent of total billed charges,,,,,,72.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,78.26,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
RESTRICTOR DEP CEMENT FEM SZ4,20534,CDM,0278,RC,,,,,,outpatient,facility,,,120.4,120.4,22.88,138.8,,78.26,,,percent of total billed charges,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,36.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,56.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,90.3,,,percent of total billed charges,,,,,,84.28,,,percent of total billed charges,,,,,,84.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,78.26,,,percent of total billed charges,,,,,,28.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,120.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,50.57,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",84.28,,,percent of total billed charges,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,83.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,85.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.28,,,percent of total billed charges,,,,,,72.24,,,percent of total billed charges,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,51.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,,percent of total billed charges,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,fee schedule,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,102.34,,,percent of total billed charges,,,,,,90.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL TWIST SMI SS 4.7 X 127,20542,CDM,0272,RC,,,,,,inpatient,facility,,,57.01,57.01,25.65,57.01,,,,,,,,,,,,,,,,,,,,48.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.91,,,percent of total billed charges,,,,,,34.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,57.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.46,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL TWIST SMI SS 4.7 X 127,20542,CDM,0272,RC,,,,,,outpatient,facility,,,57.01,57.01,10.83,1016,,37.06,,,percent of total billed charges,,,,,,,,,,,,,,,48.46,,,percent of total billed charges,,,,,,17.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,10.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,10.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,42.76,,,percent of total billed charges,,,,,,39.91,,,percent of total billed charges,,,,,,39.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,37.06,,,percent of total billed charges,,,,,,13.68,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",38.48,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,57.01,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.94,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",39.91,,,percent of total billed charges,,,,,,,,,,,,,,,57.01,,,percent of total billed charges,,,,,,39.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,40.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.91,,,percent of total billed charges,,,,,,34.21,,,percent of total billed charges,,,,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,48.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.01,,,percent of total billed charges,,,,,,57.01,,,percent of total billed charges,,,,,,24.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,57.01,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,57.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,57.01,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,57.01,,,percent of total billed charges,,,,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.01,,,fee schedule,,,,,,57.01,,,percent of total billed charges,,,,,,57.01,,,percent of total billed charges,,,,,,57.01,,,percent of total billed charges,,,,,,27.36,,,percent of total billed charges,,,,,,,,,,,,,,,33.64,,,percent of total billed charges,,,,,,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,57.01,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.46,,,percent of total billed charges,,,,,,42.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP DEP HIP SECTOR DURALOC 58MM,20551,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP DEP HIP SECTOR DURALOC 58MM,20551,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 45MM NC,20553,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 45MM NC,20553,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM COBALT CHROME 28   5,20603,CDM,0278,RC,,,,,,inpatient,facility,,,2046,2046,920.7,2046,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1636.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1534.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1125.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1236.81,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1452.66,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1432.2,,,percent of total billed charges,,,,,,1227.6,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2046,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,920.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,1329.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM COBALT CHROME 28   5,20603,CDM,0278,RC,,,,,,outpatient,facility,,,2046,2046,129.72,2046,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,613.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,388.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,388.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1534.5,,,percent of total billed charges,,,,,,1432.2,,,percent of total billed charges,,,,,,1432.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1329.9,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2046,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1432.2,,,percent of total billed charges,,,,,,1125.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,1427.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1452.66,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1432.2,,,percent of total billed charges,,,,,,1227.6,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,,percent of total billed charges,,,,,,920.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2046,,,fee schedule,,,,,,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1739.1,,,percent of total billed charges,,,,,,1534.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM COBALT CHROME 28   0,20604,CDM,0278,RC,,,,,,inpatient,facility,,,2046,2046,920.7,2046,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1636.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1534.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1125.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1236.81,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1452.66,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1432.2,,,percent of total billed charges,,,,,,1227.6,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2046,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,920.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,1329.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM COBALT CHROME 28   0,20604,CDM,0278,RC,,,,,,outpatient,facility,,,2046,2046,129.72,2046,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,613.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,388.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,388.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1534.5,,,percent of total billed charges,,,,,,1432.2,,,percent of total billed charges,,,,,,1432.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1329.9,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2046,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1432.2,,,percent of total billed charges,,,,,,1125.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,1427.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1452.66,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1432.2,,,percent of total billed charges,,,,,,1227.6,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,,percent of total billed charges,,,,,,920.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2046,,,fee schedule,,,,,,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1739.1,,,percent of total billed charges,,,,,,1534.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM COBALT CHROME 28   10,20605,CDM,0278,RC,,,,,,inpatient,facility,,,2046,2046,920.7,2046,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1636.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1534.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1125.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1236.81,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1452.66,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1432.2,,,percent of total billed charges,,,,,,1227.6,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2046,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,920.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,1329.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM COBALT CHROME 28   10,20605,CDM,0278,RC,,,,,,outpatient,facility,,,2046,2046,129.72,2046,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1739.1,,,percent of total billed charges,,,,,,613.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,388.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,388.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1534.5,,,percent of total billed charges,,,,,,1432.2,,,percent of total billed charges,,,,,,1432.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1329.9,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2046,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1432.2,,,percent of total billed charges,,,,,,1125.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,1427.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1452.66,,,percent of total billed charges,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1432.2,,,percent of total billed charges,,,,,,1227.6,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1739.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2046,,,percent of total billed charges,,,,,,920.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1534.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2046,,,fee schedule,,,,,,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,2046,,,percent of total billed charges,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1125.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2046,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1739.1,,,percent of total billed charges,,,,,,1534.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KIT GWIRE ACCESSORY .115,20638,CDM,0272,RC,,,,,,inpatient,facility,,,129.5,129.5,58.27,129.5,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,90.65,,,percent of total billed charges,,,,,,77.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,
KIT GWIRE ACCESSORY .115,20638,CDM,0272,RC,,,,,,outpatient,facility,,,129.5,129.5,24.61,1016,,84.17,,,percent of total billed charges,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,38.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,24.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,97.12,,,percent of total billed charges,,,,,,90.65,,,percent of total billed charges,,,,,,90.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,84.17,,,percent of total billed charges,,,,,,31.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",87.41,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,129.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.39,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.65,,,percent of total billed charges,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,90.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,91.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,90.65,,,percent of total billed charges,,,,,,77.7,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,55.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.12,,,percent of total billed charges,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,fee schedule,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,62.16,,,percent of total billed charges,,,,,,,,,,,,,,,76.41,,,percent of total billed charges,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.08,,,percent of total billed charges,,,,,,97.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX ST SIM1 5FR .038 X 100  i,20670,CDM,0272,RC,,,,,,inpatient,facility,,,47.77,47.77,21.5,47.77,,,,,,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,33.44,,,percent of total billed charges,,,,,,28.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX ST SIM1 5FR .038 X 100  i,20670,CDM,0272,RC,,,,,,outpatient,facility,,,47.77,47.77,9.08,1016,,31.05,,,percent of total billed charges,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,14.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,9.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,9.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.82,,,percent of total billed charges,,,,,,33.44,,,percent of total billed charges,,,,,,33.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,31.05,,,percent of total billed charges,,,,,,11.46,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.24,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,47.77,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,20.06,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",33.44,,,percent of total billed charges,,,,,,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,33.32,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,33.44,,,percent of total billed charges,,,,,,28.66,,,percent of total billed charges,,,,,,21.5,,,percent of total billed charges,,,,,,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,47.77,,,percent of total billed charges,,,,,,20.54,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,47.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,47.77,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,47.77,,,percent of total billed charges,,,,,,21.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.77,,,fee schedule,,,,,,47.77,,,percent of total billed charges,,,,,,47.77,,,percent of total billed charges,,,,,,47.77,,,percent of total billed charges,,,,,,22.93,,,percent of total billed charges,,,,,,,,,,,,,,,28.18,,,percent of total billed charges,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,47.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.6,,,percent of total billed charges,,,,,,35.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SNARE AMPLTZ GOOSE NECK 25X120  i,20678,CDM,0272,RC,,,,,,inpatient,facility,,,787.5,787.5,354.38,787.5,,,,,,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,511.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,559.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,551.25,,,percent of total billed charges,,,,,,472.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,,,,,,,,,
SNARE AMPLTZ GOOSE NECK 25X120  i,20678,CDM,0272,RC,,,,,,outpatient,facility,,,787.5,787.5,129.72,1016,,511.88,,,percent of total billed charges,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,236.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,370.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,149.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,149.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,590.62,,,percent of total billed charges,,,,,,551.25,,,percent of total billed charges,,,,,,551.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,511.88,,,percent of total billed charges,,,,,,189,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",531.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,787.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,330.75,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",551.25,,,percent of total billed charges,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,549.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,559.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,551.25,,,percent of total billed charges,,,,,,472.5,,,percent of total billed charges,,,,,,354.38,,,percent of total billed charges,,,,,,,,,,,,,,,669.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,787.5,,,percent of total billed charges,,,,,,338.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.62,,,percent of total billed charges,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,787.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.5,,,percent of total billed charges,,,,,,354.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,fee schedule,,,,,,787.5,,,percent of total billed charges,,,,,,787.5,,,percent of total billed charges,,,,,,787.5,,,percent of total billed charges,,,,,,378,,,percent of total billed charges,,,,,,,,,,,,,,,464.63,,,percent of total billed charges,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,787.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,669.38,,,percent of total billed charges,,,,,,590.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI IM 5FR 100CM  ORDER SETS OF 5   i,20729,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI IM 5FR 100CM  ORDER SETS OF 5   i,20729,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI MPA2 2SH 5FR 100CM  ORDER SETS OF,20730,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI MPA2 2SH 5FR 100CM  ORDER SETS OF,20730,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JL5 5FR 100CM  ORDER SETS OF 5,20733,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JL5 5FR 100CM  ORDER SETS OF 5,20733,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JL4 5FR 100CM  ORDER SETS OF 5,20734,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JL4 5FR 100CM  ORDER SETS OF 5,20734,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PERFORATOR CRANIAL DISP 14M,2076,CDM,0272,RC,,,,,,inpatient,facility,,,696.53,696.53,313.44,696.53,,,,,,,,,,,,,,,,,,,,592.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,487.57,,,percent of total billed charges,,,,,,417.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,592.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,696.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,313.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.05,,,percent of total billed charges,,,,,,,,,,,,,,
PERFORATOR CRANIAL DISP 14M,2076,CDM,0272,RC,,,,,,outpatient,facility,,,696.53,696.53,129.72,1016,,452.74,,,percent of total billed charges,,,,,,,,,,,,,,,592.05,,,percent of total billed charges,,,,,,208.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,327.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,132.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,132.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,522.4,,,percent of total billed charges,,,,,,487.57,,,percent of total billed charges,,,,,,487.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,452.74,,,percent of total billed charges,,,,,,167.17,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",470.16,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,696.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,292.54,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",487.57,,,percent of total billed charges,,,,,,,,,,,,,,,696.53,,,percent of total billed charges,,,,,,485.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,494.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,487.57,,,percent of total billed charges,,,,,,417.92,,,percent of total billed charges,,,,,,313.44,,,percent of total billed charges,,,,,,,,,,,,,,,592.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.53,,,percent of total billed charges,,,,,,696.53,,,percent of total billed charges,,,,,,299.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,696.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,696.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.4,,,percent of total billed charges,,,,,,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,696.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,696.53,,,percent of total billed charges,,,,,,313.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.53,,,fee schedule,,,,,,696.53,,,percent of total billed charges,,,,,,696.53,,,percent of total billed charges,,,,,,696.53,,,percent of total billed charges,,,,,,334.33,,,percent of total billed charges,,,,,,,,,,,,,,,410.95,,,percent of total billed charges,,,,,,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,696.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,592.05,,,percent of total billed charges,,,,,,522.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP HIP FEM PFC CEMENTED SZ4,20765,CDM,0278,RC,,,,,,inpatient,facility,,,4800,4800,2160,4800,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4080,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3840,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3600,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2640,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2901.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3408,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3360,,,percent of total billed charges,,,,,,2880,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4080,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4800,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2160,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4080,,,percent of total billed charges,,,,,,3120,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP HIP FEM PFC CEMENTED SZ4,20765,CDM,0278,RC,,,,,,outpatient,facility,,,4800,4800,129.72,4800,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4080,,,percent of total billed charges,,,,,,1440,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,912,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,912,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3600,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,3360,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3120,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4800,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,,percent of total billed charges,,,,,,2640,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,3348,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3408,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,,percent of total billed charges,,,,,,2880,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4080,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,,percent of total billed charges,,,,,,2160,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4800,,,fee schedule,,,,,,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4080,,,percent of total billed charges,,,,,,3600,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP HIP FEM PFC CEMENTED SZ5,20766,CDM,0278,RC,,,,,,inpatient,facility,,,4600,4600,2070,4600,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,3910,,,percent of total billed charges,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3680,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3450,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2530,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2780.7,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3266,,,percent of total billed charges,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3220,,,percent of total billed charges,,,,,,2760,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4600,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3450,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4600,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2070,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3910,,,percent of total billed charges,,,,,,2990,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP HIP FEM PFC CEMENTED SZ5,20766,CDM,0278,RC,,,,,,outpatient,facility,,,4600,4600,129.72,4600,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3910,,,percent of total billed charges,,,,,,1380,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,874,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,874,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3450,,,percent of total billed charges,,,,,,3220,,,percent of total billed charges,,,,,,3220,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2990,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4600,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3220,,,percent of total billed charges,,,,,,2530,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4600,,,percent of total billed charges,,,,,,3208.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3266,,,percent of total billed charges,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3220,,,percent of total billed charges,,,,,,2760,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4600,,,percent of total billed charges,,,,,,4600,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4600,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4600,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3450,,,percent of total billed charges,,,,,,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4600,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4600,,,percent of total billed charges,,,,,,2070,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3450,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4600,,,fee schedule,,,,,,4600,,,percent of total billed charges,,,,,,4600,,,percent of total billed charges,,,,,,4600,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2530,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4600,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3910,,,percent of total billed charges,,,,,,3450,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP HIP FEM PFC CEMENTED SZ1,20767,CDM,0278,RC,,,,,,inpatient,facility,,,4300,4300,1935,4300,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,3655,,,percent of total billed charges,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3440,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3225,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2365,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2599.35,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3053,,,percent of total billed charges,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3010,,,percent of total billed charges,,,,,,2580,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3655,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4300,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3225,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4300,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1935,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3655,,,percent of total billed charges,,,,,,2795,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP HIP FEM PFC CEMENTED SZ1,20767,CDM,0278,RC,,,,,,outpatient,facility,,,4300,4300,129.72,4300,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3655,,,percent of total billed charges,,,,,,1290,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,817,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,817,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3225,,,percent of total billed charges,,,,,,3010,,,percent of total billed charges,,,,,,3010,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2795,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4300,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3010,,,percent of total billed charges,,,,,,2365,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,,percent of total billed charges,,,,,,2999.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3053,,,percent of total billed charges,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3010,,,percent of total billed charges,,,,,,2580,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3655,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,,percent of total billed charges,,,,,,4300,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4300,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3225,,,percent of total billed charges,,,,,,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4300,,,percent of total billed charges,,,,,,1935,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3225,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4300,,,fee schedule,,,,,,4300,,,percent of total billed charges,,,,,,4300,,,percent of total billed charges,,,,,,4300,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3655,,,percent of total billed charges,,,,,,3225,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP HIP FEM PFC CEMENTED SZ2,20768,CDM,0278,RC,,,,,,inpatient,facility,,,4300,4300,1935,4300,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,3655,,,percent of total billed charges,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3440,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3225,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2365,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2599.35,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3053,,,percent of total billed charges,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3010,,,percent of total billed charges,,,,,,2580,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3655,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4300,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3225,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4300,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1935,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3655,,,percent of total billed charges,,,,,,2795,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP HIP FEM PFC CEMENTED SZ2,20768,CDM,0278,RC,,,,,,outpatient,facility,,,4300,4300,129.72,4300,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3655,,,percent of total billed charges,,,,,,1290,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,817,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,817,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3225,,,percent of total billed charges,,,,,,3010,,,percent of total billed charges,,,,,,3010,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2795,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4300,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3010,,,percent of total billed charges,,,,,,2365,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,,percent of total billed charges,,,,,,2999.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3053,,,percent of total billed charges,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3010,,,percent of total billed charges,,,,,,2580,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3655,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,,percent of total billed charges,,,,,,4300,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4300,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3225,,,percent of total billed charges,,,,,,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4300,,,percent of total billed charges,,,,,,1935,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3225,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4300,,,fee schedule,,,,,,4300,,,percent of total billed charges,,,,,,4300,,,percent of total billed charges,,,,,,4300,,,percent of total billed charges,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2365,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4300,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3655,,,percent of total billed charges,,,,,,3225,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CENTRALIZER DEP HIP PFC DIST 12MM,20769,CDM,0278,RC,,,,,,inpatient,facility,,,110,110,49.5,110,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,82.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,71.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CENTRALIZER DEP HIP PFC DIST 12MM,20769,CDM,0278,RC,,,,,,outpatient,facility,,,110,110,20.9,138.8,,71.5,,,percent of total billed charges,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,51.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,20.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,20.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,82.5,,,percent of total billed charges,,,,,,77,,,percent of total billed charges,,,,,,77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,71.5,,,percent of total billed charges,,,,,,26.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77,,,percent of total billed charges,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,76.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,,,,66,,,percent of total billed charges,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,47.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,,percent of total billed charges,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,fee schedule,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.5,,,percent of total billed charges,,,,,,82.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP HIP FEM PFC CEMENTED SZ3,20770,CDM,0278,RC,,,,,,inpatient,facility,,,4800,4800,2160,4800,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4080,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3840,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3600,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2640,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2901.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3408,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3360,,,percent of total billed charges,,,,,,2880,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4080,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4800,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2160,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4080,,,percent of total billed charges,,,,,,3120,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP HIP FEM PFC CEMENTED SZ3,20770,CDM,0278,RC,,,,,,outpatient,facility,,,4800,4800,129.72,4800,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4080,,,percent of total billed charges,,,,,,1440,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,912,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,912,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3600,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,3360,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3120,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4800,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,,percent of total billed charges,,,,,,2640,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,3348,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3408,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,,percent of total billed charges,,,,,,2880,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4080,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,,percent of total billed charges,,,,,,2160,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4800,,,fee schedule,,,,,,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4080,,,percent of total billed charges,,,,,,3600,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CENTRALIZER DEP HIP PFC DIST 13MM,20771,CDM,0278,RC,,,,,,inpatient,facility,,,110,110,49.5,110,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,82.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,71.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CENTRALIZER DEP HIP PFC DIST 13MM,20771,CDM,0278,RC,,,,,,outpatient,facility,,,110,110,20.9,138.8,,71.5,,,percent of total billed charges,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,51.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,20.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,20.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,82.5,,,percent of total billed charges,,,,,,77,,,percent of total billed charges,,,,,,77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,71.5,,,percent of total billed charges,,,,,,26.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77,,,percent of total billed charges,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,76.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,,,,66,,,percent of total billed charges,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,47.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,,percent of total billed charges,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,fee schedule,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.5,,,percent of total billed charges,,,,,,82.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KIT MED WRENCH PACEMAKER SERVICE 5873W,20775,CDM,0272,RC,,,,,,inpatient,facility,,,126,126,56.7,126,,,,,,,,,,,,,,,,,,,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,88.2,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,56.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,
KIT MED WRENCH PACEMAKER SERVICE 5873W,20775,CDM,0272,RC,,,,,,outpatient,facility,,,126,126,23.94,1016,,81.9,,,percent of total billed charges,,,,,,,,,,,,,,,107.1,,,percent of total billed charges,,,,,,37.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,23.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,23.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,94.5,,,percent of total billed charges,,,,,,88.2,,,percent of total billed charges,,,,,,88.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,81.9,,,percent of total billed charges,,,,,,30.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",85.05,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,126,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,52.92,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",88.2,,,percent of total billed charges,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,87.89,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,89.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,88.2,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,56.7,,,percent of total billed charges,,,,,,,,,,,,,,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,54.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,,,,,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,126,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,126,,,percent of total billed charges,,,,,,56.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126,,,fee schedule,,,,,,126,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,60.48,,,percent of total billed charges,,,,,,,,,,,,,,,74.34,,,percent of total billed charges,,,,,,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,126,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.1,,,percent of total billed charges,,,,,,94.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP COBALT CHROME 28   3,20776,CDM,0278,RC,,,,,,inpatient,facility,,,2026,2026,911.7,2026,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1620.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1519.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1224.72,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1438.46,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1418.2,,,percent of total billed charges,,,,,,1215.6,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2026,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,911.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,1316.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP COBALT CHROME 28   3,20776,CDM,0278,RC,,,,,,outpatient,facility,,,2026,2026,129.72,2026,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,607.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,384.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,384.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1519.5,,,percent of total billed charges,,,,,,1418.2,,,percent of total billed charges,,,,,,1418.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1316.9,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2026,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1418.2,,,percent of total billed charges,,,,,,1114.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,1413.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1438.46,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1418.2,,,percent of total billed charges,,,,,,1215.6,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,,percent of total billed charges,,,,,,911.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2026,,,fee schedule,,,,,,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1722.1,,,percent of total billed charges,,,,,,1519.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 100 56MM,20778,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 100 56MM,20778,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 28 X 10 X 58,20938,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 28 X 10 X 58,20938,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH PASSER DISP 55CM  i,2094,CDM,0272,RC,,,,,,inpatient,facility,,,500.91,500.91,225.41,500.91,,,,,,,,,,,,,,,,,,,,425.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,350.64,,,percent of total billed charges,,,,,,300.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,425.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,500.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,225.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.77,,,percent of total billed charges,,,,,,,,,,,,,,
CATH PASSER DISP 55CM  i,2094,CDM,0272,RC,,,,,,outpatient,facility,,,500.91,500.91,95.17,1016,,325.59,,,percent of total billed charges,,,,,,,,,,,,,,,425.77,,,percent of total billed charges,,,,,,150.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,235.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,95.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,95.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,375.68,,,percent of total billed charges,,,,,,350.64,,,percent of total billed charges,,,,,,350.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,325.59,,,percent of total billed charges,,,,,,120.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",338.11,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500.91,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,210.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",350.64,,,percent of total billed charges,,,,,,,,,,,,,,,500.91,,,percent of total billed charges,,,,,,349.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,355.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,350.64,,,percent of total billed charges,,,,,,300.55,,,percent of total billed charges,,,,,,225.41,,,percent of total billed charges,,,,,,,,,,,,,,,425.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.91,,,percent of total billed charges,,,,,,500.91,,,percent of total billed charges,,,,,,215.39,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,500.91,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,500.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.68,,,percent of total billed charges,,,,,,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.91,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,500.91,,,percent of total billed charges,,,,,,225.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.91,,,fee schedule,,,,,,500.91,,,percent of total billed charges,,,,,,500.91,,,percent of total billed charges,,,,,,500.91,,,percent of total billed charges,,,,,,240.44,,,percent of total billed charges,,,,,,,,,,,,,,,295.54,,,percent of total billed charges,,,,,,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500.91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,425.77,,,percent of total billed charges,,,,,,375.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CENTRALIZER DEP HIP PFC DIST 10MM,20941,CDM,0278,RC,,,,,,inpatient,facility,,,110,110,49.5,110,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,82.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,71.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CENTRALIZER DEP HIP PFC DIST 10MM,20941,CDM,0278,RC,,,,,,outpatient,facility,,,110,110,20.9,138.8,,71.5,,,percent of total billed charges,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,51.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,20.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,20.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,60.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,82.5,,,percent of total billed charges,,,,,,77,,,percent of total billed charges,,,,,,77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,71.5,,,percent of total billed charges,,,,,,26.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77,,,percent of total billed charges,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,76.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,,,,66,,,percent of total billed charges,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,47.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110,,,percent of total billed charges,,,,,,49.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,,fee schedule,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,110,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.5,,,percent of total billed charges,,,,,,82.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T LOCK 5.0 X 40,20946,CDM,0278,RC,,,,,,inpatient,facility,,,169.08,169.08,76.09,169.08,,,,,,,,,,,,,,,,,,,,143.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.21,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",120.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.36,,,percent of total billed charges,,,,,,101.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,143.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,169.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.72,,,percent of total billed charges,,,,,,109.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T LOCK 5.0 X 40,20946,CDM,0278,RC,,,,,,outpatient,facility,,,169.08,169.08,32.13,169.08,,109.9,,,percent of total billed charges,,,,,,,,,,,,,,,143.72,,,percent of total billed charges,,,,,,50.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.99,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.99,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.99,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.99,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126.81,,,percent of total billed charges,,,,,,118.36,,,percent of total billed charges,,,,,,118.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.9,,,percent of total billed charges,,,,,,40.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,169.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,71.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.36,,,percent of total billed charges,,,,,,,,,,,,,,,169.08,,,percent of total billed charges,,,,,,117.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,120.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.36,,,percent of total billed charges,,,,,,101.45,,,percent of total billed charges,,,,,,76.09,,,percent of total billed charges,,,,,,,,,,,,,,,143.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.08,,,percent of total billed charges,,,,,,169.08,,,percent of total billed charges,,,,,,72.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,169.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,169.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.81,,,percent of total billed charges,,,,,,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,169.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169.08,,,percent of total billed charges,,,,,,76.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.08,,,fee schedule,,,,,,169.08,,,percent of total billed charges,,,,,,169.08,,,percent of total billed charges,,,,,,169.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,169.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.72,,,percent of total billed charges,,,,,,126.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T LOCK 5.0 X 30,20947,CDM,0278,RC,,,,,,inpatient,facility,,,169,169,76.05,169,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.16,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,109.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T LOCK 5.0 X 30,20947,CDM,0278,RC,,,,,,outpatient,facility,,,169,169,32.11,169,,109.85,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,50.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126.75,,,percent of total billed charges,,,,,,118.3,,,percent of total billed charges,,,,,,118.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.85,,,percent of total billed charges,,,,,,40.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,169,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.3,,,percent of total billed charges,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,117.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,72.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,fee schedule,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.65,,,percent of total billed charges,,,,,,126.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SET INFUS PULSE SPRAY 5FR 135 X 10  i,21002,CDM,0272,RC,,,,,,inpatient,facility,,,945,945,425.25,945,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,614.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,670.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,661.5,,,percent of total billed charges,,,,,,567,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,
SET INFUS PULSE SPRAY 5FR 135 X 10  i,21002,CDM,0272,RC,,,,,,outpatient,facility,,,945,945,129.72,1016,,614.25,,,percent of total billed charges,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,283.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,444.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,708.76,,,percent of total billed charges,,,,,,661.5,,,percent of total billed charges,,,,,,661.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,614.25,,,percent of total billed charges,,,,,,226.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",637.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,945,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,396.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",661.5,,,percent of total billed charges,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,659.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,670.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,661.5,,,percent of total billed charges,,,,,,567,,,percent of total billed charges,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,406.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,,percent of total billed charges,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,fee schedule,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,453.6,,,percent of total billed charges,,,,,,,,,,,,,,,557.55,,,percent of total billed charges,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,803.25,,,percent of total billed charges,,,,,,708.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GUIDE PIN SMI TH STRL 2.4MM,21027,CDM,0272,RC,,,,,,inpatient,facility,,,45.85,45.85,20.63,45.85,,,,,,,,,,,,,,,,,,,,38.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.1,,,percent of total billed charges,,,,,,27.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,38.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,45.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,20.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.97,,,percent of total billed charges,,,,,,,,,,,,,,
GUIDE PIN SMI TH STRL 2.4MM,21027,CDM,0272,RC,,,,,,outpatient,facility,,,45.85,45.85,8.71,1016,,29.8,,,percent of total billed charges,,,,,,,,,,,,,,,38.97,,,percent of total billed charges,,,,,,13.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,34.39,,,percent of total billed charges,,,,,,32.09,,,percent of total billed charges,,,,,,32.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,29.8,,,percent of total billed charges,,,,,,11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",30.95,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,45.85,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.09,,,percent of total billed charges,,,,,,,,,,,,,,,45.85,,,percent of total billed charges,,,,,,31.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,32.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.1,,,percent of total billed charges,,,,,,27.51,,,percent of total billed charges,,,,,,20.63,,,percent of total billed charges,,,,,,,,,,,,,,,38.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.85,,,percent of total billed charges,,,,,,45.85,,,percent of total billed charges,,,,,,19.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,45.85,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,45.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,45.85,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,45.85,,,percent of total billed charges,,,,,,20.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.85,,,fee schedule,,,,,,45.85,,,percent of total billed charges,,,,,,45.85,,,percent of total billed charges,,,,,,45.85,,,percent of total billed charges,,,,,,22.01,,,percent of total billed charges,,,,,,,,,,,,,,,27.05,,,percent of total billed charges,,,,,,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,45.85,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,38.97,,,percent of total billed charges,,,,,,34.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL TWIST SMI 2.7MM,21028,CDM,0272,RC,,,,,,inpatient,facility,,,58.27,58.27,26.22,58.27,,,,,,,,,,,,,,,,,,,,49.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,40.79,,,percent of total billed charges,,,,,,34.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,49.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.53,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL TWIST SMI 2.7MM,21028,CDM,0272,RC,,,,,,outpatient,facility,,,58.27,58.27,11.07,1016,,37.88,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,percent of total billed charges,,,,,,17.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,27.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,11.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,11.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,43.7,,,percent of total billed charges,,,,,,40.79,,,percent of total billed charges,,,,,,40.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,37.88,,,percent of total billed charges,,,,,,13.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",39.33,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,58.27,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.47,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",40.79,,,percent of total billed charges,,,,,,,,,,,,,,,58.27,,,percent of total billed charges,,,,,,40.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,41.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,40.79,,,percent of total billed charges,,,,,,34.96,,,percent of total billed charges,,,,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,49.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.27,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,25.06,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,58.27,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.7,,,percent of total billed charges,,,,,,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.27,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,58.27,,,percent of total billed charges,,,,,,26.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.27,,,fee schedule,,,,,,58.27,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,27.97,,,percent of total billed charges,,,,,,,,,,,,,,,34.38,,,percent of total billed charges,,,,,,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,58.27,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,49.53,,,percent of total billed charges,,,,,,43.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SMI HIP R T RECON FEM PLUS LT 10 X 40,21030,CDM,0278,RC,,,,,,inpatient,facility,,,2322,2322,1044.9,2322,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1973.7,,,percent of total billed charges,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1741.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1277.1,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1403.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1648.62,,,percent of total billed charges,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1625.4,,,percent of total billed charges,,,,,,1393.2,,,percent of total billed charges,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1973.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1277.1,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2322,,,percent of total billed charges,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1741.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2322,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1044.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1973.7,,,percent of total billed charges,,,,,,1509.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SMI HIP R T RECON FEM PLUS LT 10 X 40,21030,CDM,0278,RC,,,,,,outpatient,facility,,,2322,2322,129.72,2322,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1973.7,,,percent of total billed charges,,,,,,696.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,441.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,441.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1741.5,,,percent of total billed charges,,,,,,1625.4,,,percent of total billed charges,,,,,,1625.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1509.3,,,percent of total billed charges,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2322,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1625.4,,,percent of total billed charges,,,,,,1277.1,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2322,,,percent of total billed charges,,,,,,1619.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1648.62,,,percent of total billed charges,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1625.4,,,percent of total billed charges,,,,,,1393.2,,,percent of total billed charges,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1973.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1277.1,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2322,,,percent of total billed charges,,,,,,2322,,,percent of total billed charges,,,,,,1277.1,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2322,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2322,,,percent of total billed charges,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1741.5,,,percent of total billed charges,,,,,,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2322,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2322,,,percent of total billed charges,,,,,,1044.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1741.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2322,,,fee schedule,,,,,,2322,,,percent of total billed charges,,,,,,2322,,,percent of total billed charges,,,,,,2322,,,percent of total billed charges,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1277.1,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2322,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1973.7,,,percent of total billed charges,,,,,,1741.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP COBALT CHROME 28   0,21091,CDM,0278,RC,,,,,,inpatient,facility,,,2026,2026,911.7,2026,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1620.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1519.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1224.72,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1438.46,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1418.2,,,percent of total billed charges,,,,,,1215.6,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2026,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,911.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,1316.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP COBALT CHROME 28   0,21091,CDM,0278,RC,,,,,,outpatient,facility,,,2026,2026,129.72,2026,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,607.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,384.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,384.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1519.5,,,percent of total billed charges,,,,,,1418.2,,,percent of total billed charges,,,,,,1418.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1316.9,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2026,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1418.2,,,percent of total billed charges,,,,,,1114.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,1413.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1438.46,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1418.2,,,percent of total billed charges,,,,,,1215.6,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,,percent of total billed charges,,,,,,911.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2026,,,fee schedule,,,,,,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1722.1,,,percent of total billed charges,,,,,,1519.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 100 52MM,21092,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 100 52MM,21092,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 28 X 10 X 52,21093,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 28 X 10 X 52,21093,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INTRO COOK PEEL AWAY 9.0 30CM,21134,CDM,0272,RC,,,,,,inpatient,facility,,,199.46,199.46,89.76,199.46,,,,,,,,,,,,,,,,,,,,169.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,139.62,,,percent of total billed charges,,,,,,119.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,169.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,199.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,89.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.54,,,percent of total billed charges,,,,,,,,,,,,,,
INTRO COOK PEEL AWAY 9.0 30CM,21134,CDM,0272,RC,,,,,,outpatient,facility,,,199.46,199.46,37.9,1016,,129.65,,,percent of total billed charges,,,,,,,,,,,,,,,169.54,,,percent of total billed charges,,,,,,59.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,93.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,37.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,149.6,,,percent of total billed charges,,,,,,139.62,,,percent of total billed charges,,,,,,139.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,129.65,,,percent of total billed charges,,,,,,47.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",134.64,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,199.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,83.77,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",139.62,,,percent of total billed charges,,,,,,,,,,,,,,,199.46,,,percent of total billed charges,,,,,,139.12,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,141.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,139.62,,,percent of total billed charges,,,,,,119.68,,,percent of total billed charges,,,,,,89.76,,,percent of total billed charges,,,,,,,,,,,,,,,169.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.46,,,percent of total billed charges,,,,,,199.46,,,percent of total billed charges,,,,,,85.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,199.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,199.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.6,,,percent of total billed charges,,,,,,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,199.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,199.46,,,percent of total billed charges,,,,,,89.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.46,,,fee schedule,,,,,,199.46,,,percent of total billed charges,,,,,,199.46,,,percent of total billed charges,,,,,,199.46,,,percent of total billed charges,,,,,,95.74,,,percent of total billed charges,,,,,,,,,,,,,,,117.68,,,percent of total billed charges,,,,,,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,199.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,169.54,,,percent of total billed charges,,,,,,149.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SPECULA CASPAR TWIST 1.7MM,2131,CDM,0272,RC,,,,,,inpatient,facility,,,1803.02,1803.02,811.36,1803.02,,,,,,,,,,,,,,,,,,,,1532.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1352.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1171.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1280.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1262.11,,,percent of total billed charges,,,,,,1081.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1532.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1803.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1352.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1803.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,811.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1532.57,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SPECULA CASPAR TWIST 1.7MM,2131,CDM,0272,RC,,,,,,outpatient,facility,,,1803.02,1803.02,129.72,1803.02,,1171.96,,,percent of total billed charges,,,,,,,,,,,,,,,1532.57,,,percent of total billed charges,,,,,,540.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,847.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,342.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,342.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1352.27,,,percent of total billed charges,,,,,,1262.11,,,percent of total billed charges,,,,,,1262.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1171.96,,,percent of total billed charges,,,,,,432.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1217.04,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1803.02,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,757.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1262.11,,,percent of total billed charges,,,,,,,,,,,,,,,1803.02,,,percent of total billed charges,,,,,,1257.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1280.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1262.11,,,percent of total billed charges,,,,,,1081.81,,,percent of total billed charges,,,,,,811.36,,,percent of total billed charges,,,,,,,,,,,,,,,1532.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1803.02,,,percent of total billed charges,,,,,,1803.02,,,percent of total billed charges,,,,,,775.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1803.02,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1803.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1352.26,,,percent of total billed charges,,,,,,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1803.02,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1803.02,,,percent of total billed charges,,,,,,811.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1352.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1803.02,,,fee schedule,,,,,,1803.02,,,percent of total billed charges,,,,,,1803.02,,,percent of total billed charges,,,,,,1803.02,,,percent of total billed charges,,,,,,865.45,,,percent of total billed charges,,,,,,,,,,,,,,,1063.78,,,percent of total billed charges,,,,,,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1803.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1532.57,,,percent of total billed charges,,,,,,1352.27,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BREAST SALINE SILTEX CONT PROF SPECTRUM 550ML  c,21330,CDM,0278,RC,,,,,,inpatient,facility,,,2320,2320,1044,2320,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1972,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1740,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1276,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1402.44,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1647.2,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1624,,,percent of total billed charges,,,,,,1392,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1972,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2320,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1044,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972,,,percent of total billed charges,,,,,,1508,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BREAST SALINE SILTEX CONT PROF SPECTRUM 550ML  c,21330,CDM,0278,RC,,,,,,outpatient,facility,,,2320,2320,129.72,2320,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1972,,,percent of total billed charges,,,,,,696,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,440.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,440.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1740,,,percent of total billed charges,,,,,,1624,,,percent of total billed charges,,,,,,1624,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1508,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2320,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1624,,,percent of total billed charges,,,,,,1276,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,1618.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1647.2,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1624,,,percent of total billed charges,,,,,,1392,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1972,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,,percent of total billed charges,,,,,,1044,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2320,,,fee schedule,,,,,,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1972,,,percent of total billed charges,,,,,,1740,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BREAST SALINE SILTEX CONT PROF SPECTRUM 650ML  c,21331,CDM,0278,RC,,,,,,inpatient,facility,,,2320,2320,1044,2320,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1972,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1740,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1276,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1402.44,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1647.2,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1624,,,percent of total billed charges,,,,,,1392,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1972,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2320,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1044,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972,,,percent of total billed charges,,,,,,1508,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BREAST SALINE SILTEX CONT PROF SPECTRUM 650ML  c,21331,CDM,0278,RC,,,,,,outpatient,facility,,,2320,2320,129.72,2320,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1972,,,percent of total billed charges,,,,,,696,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,440.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,440.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1740,,,percent of total billed charges,,,,,,1624,,,percent of total billed charges,,,,,,1624,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1508,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2320,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1624,,,percent of total billed charges,,,,,,1276,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,1618.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1647.2,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1624,,,percent of total billed charges,,,,,,1392,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1972,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,,percent of total billed charges,,,,,,1044,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2320,,,fee schedule,,,,,,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1972,,,percent of total billed charges,,,,,,1740,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BREAST SALINE SILTEX CONT PROF SPECTRUM 350ML  c,21332,CDM,0278,RC,,,,,,inpatient,facility,,,2320,2320,1044,2320,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1972,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1740,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1276,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1402.44,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1647.2,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1624,,,percent of total billed charges,,,,,,1392,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1972,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2320,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1044,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972,,,percent of total billed charges,,,,,,1508,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BREAST SALINE SILTEX CONT PROF SPECTRUM 350ML  c,21332,CDM,0278,RC,,,,,,outpatient,facility,,,2320,2320,129.72,2320,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1972,,,percent of total billed charges,,,,,,696,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,440.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,440.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1740,,,percent of total billed charges,,,,,,1624,,,percent of total billed charges,,,,,,1624,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1508,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2320,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1624,,,percent of total billed charges,,,,,,1276,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,1618.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1647.2,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1624,,,percent of total billed charges,,,,,,1392,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1972,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,,percent of total billed charges,,,,,,1044,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2320,,,fee schedule,,,,,,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1972,,,percent of total billed charges,,,,,,1740,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BREAST SALINE SILTEX CONT PROF SPECTRUM 450ML  c,21333,CDM,0278,RC,,,,,,inpatient,facility,,,2320,2320,1044,2320,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1972,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1856,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1740,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1276,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1402.44,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1647.2,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1624,,,percent of total billed charges,,,,,,1392,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1972,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2320,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1044,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1972,,,percent of total billed charges,,,,,,1508,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BREAST SALINE SILTEX CONT PROF SPECTRUM 450ML  c,21333,CDM,0278,RC,,,,,,outpatient,facility,,,2320,2320,129.72,2320,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1972,,,percent of total billed charges,,,,,,696,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,440.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,440.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1740,,,percent of total billed charges,,,,,,1624,,,percent of total billed charges,,,,,,1624,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1508,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2320,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1624,,,percent of total billed charges,,,,,,1276,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,1618.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1647.2,,,percent of total billed charges,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1624,,,percent of total billed charges,,,,,,1392,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1972,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1276,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2320,,,percent of total billed charges,,,,,,1044,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1740,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2320,,,fee schedule,,,,,,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,2320,,,percent of total billed charges,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1276,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2320,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1972,,,percent of total billed charges,,,,,,1740,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WASHER SMI 1.5MM,21436,CDM,0278,RC,,,,,,inpatient,facility,,,3.5,3.5,1.57,3.5,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2.62,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,,,,2.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,,,,2.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WASHER SMI 1.5MM,21436,CDM,0278,RC,,,,,,outpatient,facility,,,3.5,3.5,0.67,138.8,,2.27,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.93,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2.62,,,percent of total billed charges,,,,,,2.45,,,percent of total billed charges,,,,,,2.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.27,,,percent of total billed charges,,,,,,0.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,3.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.47,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.45,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,2.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.45,,,percent of total billed charges,,,,,,2.1,,,percent of total billed charges,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,3.5,,,percent of total billed charges,,,,,,1.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.62,,,percent of total billed charges,,,,,,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.5,,,percent of total billed charges,,,,,,1.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,fee schedule,,,,,,3.5,,,percent of total billed charges,,,,,,3.5,,,percent of total billed charges,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.98,,,percent of total billed charges,,,,,,2.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WASHER SMI 1.0MM,21437,CDM,0278,RC,,,,,,inpatient,facility,,,3,3,1.35,3,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.81,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,,,,1.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,1.95,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WASHER SMI 1.0MM,21437,CDM,0278,RC,,,,,,outpatient,facility,,,3,3,0.57,138.8,,1.95,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,0.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1.65,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.65,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1.65,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.65,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2.25,,,percent of total billed charges,,,,,,2.1,,,percent of total billed charges,,,,,,2.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1.95,,,percent of total billed charges,,,,,,0.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.1,,,percent of total billed charges,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,2.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.1,,,percent of total billed charges,,,,,,1.8,,,percent of total billed charges,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,2.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,3,,,percent of total billed charges,,,,,,1.29,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3,,,percent of total billed charges,,,,,,1.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,,fee schedule,,,,,,3,,,percent of total billed charges,,,,,,3,,,percent of total billed charges,,,,,,3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.55,,,percent of total billed charges,,,,,,2.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T HUM LOCK SS 4.0 X 44,21439,CDM,0278,RC,,,,,,inpatient,facility,,,166.3,166.3,74.84,166.3,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,124.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.53,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,99.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,108.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T HUM LOCK SS 4.0 X 44,21439,CDM,0278,RC,,,,,,outpatient,facility,,,166.3,166.3,31.6,166.3,,108.09,,,percent of total billed charges,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,49.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,124.72,,,percent of total billed charges,,,,,,116.41,,,percent of total billed charges,,,,,,116.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,108.1,,,percent of total billed charges,,,,,,39.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,166.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,69.85,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",116.41,,,percent of total billed charges,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,115.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,99.78,,,percent of total billed charges,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,71.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,,percent of total billed charges,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,fee schedule,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.36,,,percent of total billed charges,,,,,,124.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T HUM LOCK SS 4.0 X 48,21440,CDM,0278,RC,,,,,,inpatient,facility,,,166.3,166.3,74.84,166.3,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,124.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.53,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,99.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,108.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T HUM LOCK SS 4.0 X 48,21440,CDM,0278,RC,,,,,,outpatient,facility,,,166.3,166.3,31.6,166.3,,108.09,,,percent of total billed charges,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,49.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,124.72,,,percent of total billed charges,,,,,,116.41,,,percent of total billed charges,,,,,,116.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,108.1,,,percent of total billed charges,,,,,,39.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,166.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,69.85,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",116.41,,,percent of total billed charges,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,115.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,99.78,,,percent of total billed charges,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,71.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,,percent of total billed charges,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,fee schedule,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.36,,,percent of total billed charges,,,,,,124.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T HUM LOCK SS 4.0 X 20,21441,CDM,0278,RC,,,,,,inpatient,facility,,,166.3,166.3,74.84,166.3,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,124.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.53,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,99.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,108.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T HUM LOCK SS 4.0 X 20,21441,CDM,0278,RC,,,,,,outpatient,facility,,,166.3,166.3,31.6,166.3,,108.09,,,percent of total billed charges,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,49.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,124.72,,,percent of total billed charges,,,,,,116.41,,,percent of total billed charges,,,,,,116.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,108.1,,,percent of total billed charges,,,,,,39.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,166.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,69.85,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",116.41,,,percent of total billed charges,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,115.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,99.78,,,percent of total billed charges,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,71.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,,percent of total billed charges,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,fee schedule,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.36,,,percent of total billed charges,,,,,,124.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD SMI GUIDE REAMER 2.0 X 700,21448,CDM,0272,RC,,,,,,inpatient,facility,,,223.33,223.33,100.5,223.33,,,,,,,,,,,,,,,,,,,,189.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,156.33,,,percent of total billed charges,,,,,,134,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,189.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,223.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,100.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.83,,,percent of total billed charges,,,,,,,,,,,,,,
ROD SMI GUIDE REAMER 2.0 X 700,21448,CDM,0272,RC,,,,,,outpatient,facility,,,223.33,223.33,42.43,1016,,145.16,,,percent of total billed charges,,,,,,,,,,,,,,,189.83,,,percent of total billed charges,,,,,,67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,104.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,42.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,42.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,167.5,,,percent of total billed charges,,,,,,156.33,,,percent of total billed charges,,,,,,156.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,145.16,,,percent of total billed charges,,,,,,53.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",150.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,223.33,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.8,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",156.33,,,percent of total billed charges,,,,,,,,,,,,,,,223.33,,,percent of total billed charges,,,,,,155.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,158.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,156.33,,,percent of total billed charges,,,,,,134,,,percent of total billed charges,,,,,,100.5,,,percent of total billed charges,,,,,,,,,,,,,,,189.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.33,,,percent of total billed charges,,,,,,223.33,,,percent of total billed charges,,,,,,96.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,223.33,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,223.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.5,,,percent of total billed charges,,,,,,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,223.33,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,223.33,,,percent of total billed charges,,,,,,100.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.33,,,fee schedule,,,,,,223.33,,,percent of total billed charges,,,,,,223.33,,,percent of total billed charges,,,,,,223.33,,,percent of total billed charges,,,,,,107.2,,,percent of total billed charges,,,,,,,,,,,,,,,131.76,,,percent of total billed charges,,,,,,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,223.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,189.83,,,percent of total billed charges,,,,,,167.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD SMI GUIDE STRT 2.4MM,21449,CDM,0272,RC,,,,,,inpatient,facility,,,203.98,203.98,91.79,203.98,,,,,,,,,,,,,,,,,,,,173.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.79,,,percent of total billed charges,,,,,,122.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,173.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,203.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,91.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.38,,,percent of total billed charges,,,,,,,,,,,,,,
ROD SMI GUIDE STRT 2.4MM,21449,CDM,0272,RC,,,,,,outpatient,facility,,,203.98,203.98,38.76,1016,,132.59,,,percent of total billed charges,,,,,,,,,,,,,,,173.38,,,percent of total billed charges,,,,,,61.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,95.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,38.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,38.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,152.99,,,percent of total billed charges,,,,,,142.79,,,percent of total billed charges,,,,,,142.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,132.59,,,percent of total billed charges,,,,,,48.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",137.69,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,203.98,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.67,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",142.79,,,percent of total billed charges,,,,,,,,,,,,,,,203.98,,,percent of total billed charges,,,,,,142.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,144.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.79,,,percent of total billed charges,,,,,,122.39,,,percent of total billed charges,,,,,,91.79,,,percent of total billed charges,,,,,,,,,,,,,,,173.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.98,,,percent of total billed charges,,,,,,203.98,,,percent of total billed charges,,,,,,87.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,203.98,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,203.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.98,,,percent of total billed charges,,,,,,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,203.98,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,203.98,,,percent of total billed charges,,,,,,91.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.98,,,fee schedule,,,,,,203.98,,,percent of total billed charges,,,,,,203.98,,,percent of total billed charges,,,,,,203.98,,,percent of total billed charges,,,,,,97.91,,,percent of total billed charges,,,,,,,,,,,,,,,120.35,,,percent of total billed charges,,,,,,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,203.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,173.38,,,percent of total billed charges,,,,,,152.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN SMI TROCAR 2.7 X 216,21450,CDM,0278,RC,,,,,,inpatient,facility,,,88.06,88.06,39.63,88.06,,,,,,,,,,,,,,,,,,,,74.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.45,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,66.05,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.23,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.64,,,percent of total billed charges,,,,,,52.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,88.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.85,,,percent of total billed charges,,,,,,57.24,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN SMI TROCAR 2.7 X 216,21450,CDM,0278,RC,,,,,,outpatient,facility,,,88.06,88.06,16.73,138.8,,57.24,,,percent of total billed charges,,,,,,,,,,,,,,,74.85,,,percent of total billed charges,,,,,,26.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.04,,,percent of total billed charges,,,,,,61.64,,,percent of total billed charges,,,,,,61.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.24,,,percent of total billed charges,,,,,,21.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,88.06,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.64,,,percent of total billed charges,,,,,,,,,,,,,,,88.06,,,percent of total billed charges,,,,,,61.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.64,,,percent of total billed charges,,,,,,52.84,,,percent of total billed charges,,,,,,39.63,,,percent of total billed charges,,,,,,,,,,,,,,,74.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.06,,,percent of total billed charges,,,,,,88.06,,,percent of total billed charges,,,,,,37.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,88.06,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,88.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.04,,,percent of total billed charges,,,,,,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,88.06,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88.06,,,percent of total billed charges,,,,,,39.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.06,,,fee schedule,,,,,,88.06,,,percent of total billed charges,,,,,,88.06,,,percent of total billed charges,,,,,,88.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,88.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.85,,,percent of total billed charges,,,,,,66.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL TWIST SMI 2.7 X 216,21451,CDM,0272,RC,,,,,,inpatient,facility,,,279.26,279.26,125.67,279.26,,,,,,,,,,,,,,,,,,,,237.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,181.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,195.48,,,percent of total billed charges,,,,,,167.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,237.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,279.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,125.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.37,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL TWIST SMI 2.7 X 216,21451,CDM,0272,RC,,,,,,outpatient,facility,,,279.26,279.26,53.06,1016,,181.52,,,percent of total billed charges,,,,,,,,,,,,,,,237.37,,,percent of total billed charges,,,,,,83.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,131.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,53.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,53.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,209.44,,,percent of total billed charges,,,,,,195.48,,,percent of total billed charges,,,,,,195.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,181.52,,,percent of total billed charges,,,,,,67.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",188.5,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,279.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,117.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",195.48,,,percent of total billed charges,,,,,,,,,,,,,,,279.26,,,percent of total billed charges,,,,,,194.78,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,198.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,195.48,,,percent of total billed charges,,,,,,167.56,,,percent of total billed charges,,,,,,125.67,,,percent of total billed charges,,,,,,,,,,,,,,,237.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.26,,,percent of total billed charges,,,,,,279.26,,,percent of total billed charges,,,,,,120.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,279.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,279.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.44,,,percent of total billed charges,,,,,,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,279.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,279.26,,,percent of total billed charges,,,,,,125.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.26,,,fee schedule,,,,,,279.26,,,percent of total billed charges,,,,,,279.26,,,percent of total billed charges,,,,,,279.26,,,percent of total billed charges,,,,,,134.04,,,percent of total billed charges,,,,,,,,,,,,,,,164.76,,,percent of total billed charges,,,,,,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,279.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,237.37,,,percent of total billed charges,,,,,,209.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WASHER SMI SLOTTED 3MM,21476,CDM,0278,RC,,,,,,inpatient,facility,,,13.6,13.6,6.12,13.6,,,,,,,,,,,,,,,,,,,,11.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.88,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.22,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",9.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,9.52,,,percent of total billed charges,,,,,,8.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.56,,,percent of total billed charges,,,,,,8.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WASHER SMI SLOTTED 3MM,21476,CDM,0278,RC,,,,,,outpatient,facility,,,13.6,13.6,2.58,138.8,,8.84,,,percent of total billed charges,,,,,,,,,,,,,,,11.56,,,percent of total billed charges,,,,,,4.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.48,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.48,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7.48,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.48,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10.2,,,percent of total billed charges,,,,,,9.52,,,percent of total billed charges,,,,,,9.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8.84,,,percent of total billed charges,,,,,,3.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,13.6,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.71,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",9.52,,,percent of total billed charges,,,,,,,,,,,,,,,13.6,,,percent of total billed charges,,,,,,9.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,9.52,,,percent of total billed charges,,,,,,8.16,,,percent of total billed charges,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,11.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.6,,,percent of total billed charges,,,,,,13.6,,,percent of total billed charges,,,,,,5.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,13.6,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,,,,,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13.6,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13.6,,,percent of total billed charges,,,,,,6.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.6,,,fee schedule,,,,,,13.6,,,percent of total billed charges,,,,,,13.6,,,percent of total billed charges,,,,,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13.6,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11.56,,,percent of total billed charges,,,,,,10.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T HUM LOCK SS 4.0 X 22,21478,CDM,0278,RC,,,,,,inpatient,facility,,,162.72,162.72,73.22,162.72,,,,,,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,122.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",115.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.9,,,percent of total billed charges,,,,,,97.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,105.77,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T HUM LOCK SS 4.0 X 22,21478,CDM,0278,RC,,,,,,outpatient,facility,,,162.72,162.72,30.92,162.72,,105.77,,,percent of total billed charges,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,48.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,76.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,30.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,89.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,89.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,89.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,122.04,,,percent of total billed charges,,,,,,113.9,,,percent of total billed charges,,,,,,113.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,105.77,,,percent of total billed charges,,,,,,39.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,162.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.34,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",113.9,,,percent of total billed charges,,,,,,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,113.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,115.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.9,,,percent of total billed charges,,,,,,97.63,,,percent of total billed charges,,,,,,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,162.72,,,percent of total billed charges,,,,,,69.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,162.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.04,,,percent of total billed charges,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,162.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.72,,,percent of total billed charges,,,,,,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,,fee schedule,,,,,,162.72,,,percent of total billed charges,,,,,,162.72,,,percent of total billed charges,,,,,,162.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,138.31,,,percent of total billed charges,,,,,,122.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T HUM LOCK SS 4.0 X 42,21479,CDM,0278,RC,,,,,,inpatient,facility,,,166.3,166.3,74.84,166.3,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,124.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.53,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,99.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,108.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T HUM LOCK SS 4.0 X 42,21479,CDM,0278,RC,,,,,,outpatient,facility,,,166.3,166.3,31.6,166.3,,108.09,,,percent of total billed charges,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,49.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,91.47,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,124.72,,,percent of total billed charges,,,,,,116.41,,,percent of total billed charges,,,,,,116.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,108.1,,,percent of total billed charges,,,,,,39.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,166.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,69.85,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",116.41,,,percent of total billed charges,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,115.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,118.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,99.78,,,percent of total billed charges,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,71.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.72,,,percent of total billed charges,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,166.3,,,percent of total billed charges,,,,,,74.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,,fee schedule,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,166.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,166.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.36,,,percent of total billed charges,,,,,,124.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WIRE SMI ILIZAROV BAYONET CORT SS 1.2 X 300,21480,CDM,0278,RC,,,,,,inpatient,facility,,,31,31,13.95,31,,,,,,,,,,,,,,,,,,,,26.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,23.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.74,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",22.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,21.7,,,percent of total billed charges,,,,,,18.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,26.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.35,,,percent of total billed charges,,,,,,20.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WIRE SMI ILIZAROV BAYONET CORT SS 1.2 X 300,21480,CDM,0278,RC,,,,,,outpatient,facility,,,31,31,5.89,138.8,,20.15,,,percent of total billed charges,,,,,,,,,,,,,,,26.35,,,percent of total billed charges,,,,,,9.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,5.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,17.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,17.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23.25,,,percent of total billed charges,,,,,,21.7,,,percent of total billed charges,,,,,,21.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,20.15,,,percent of total billed charges,,,,,,7.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,31,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,13.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",21.7,,,percent of total billed charges,,,,,,,,,,,,,,,31,,,percent of total billed charges,,,,,,21.62,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,22.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,21.7,,,percent of total billed charges,,,,,,18.6,,,percent of total billed charges,,,,,,13.95,,,percent of total billed charges,,,,,,,,,,,,,,,26.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31,,,percent of total billed charges,,,,,,31,,,percent of total billed charges,,,,,,13.33,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,31,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,,,,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,31,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,31,,,percent of total billed charges,,,,,,13.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31,,,fee schedule,,,,,,31,,,percent of total billed charges,,,,,,31,,,percent of total billed charges,,,,,,31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,26.35,,,percent of total billed charges,,,,,,23.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD SMI ILIZAROV TH 150MM,21481,CDM,0272,RC,,,,,,inpatient,facility,,,52.5,52.5,23.63,52.5,,,,,,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,36.75,,,percent of total billed charges,,,,,,31.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,52.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,23.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,,,,,,,,,,,,,
ROD SMI ILIZAROV TH 150MM,21481,CDM,0272,RC,,,,,,outpatient,facility,,,52.5,52.5,9.97,1016,,34.13,,,percent of total billed charges,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,,,,,15.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,9.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,9.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,39.38,,,percent of total billed charges,,,,,,36.75,,,percent of total billed charges,,,,,,36.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,34.13,,,percent of total billed charges,,,,,,12.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",35.44,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,52.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.05,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",36.75,,,percent of total billed charges,,,,,,,,,,,,,,,52.5,,,percent of total billed charges,,,,,,36.62,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,37.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,36.75,,,percent of total billed charges,,,,,,31.5,,,percent of total billed charges,,,,,,23.63,,,percent of total billed charges,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.5,,,percent of total billed charges,,,,,,52.5,,,percent of total billed charges,,,,,,22.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,52.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,52.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.38,,,percent of total billed charges,,,,,,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,52.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,52.5,,,percent of total billed charges,,,,,,23.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.5,,,fee schedule,,,,,,52.5,,,percent of total billed charges,,,,,,52.5,,,percent of total billed charges,,,,,,52.5,,,percent of total billed charges,,,,,,25.2,,,percent of total billed charges,,,,,,,,,,,,,,,30.98,,,percent of total billed charges,,,,,,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,52.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,44.62,,,percent of total billed charges,,,,,,39.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC PVT W TELEMETRY,21490001,CDM,0214,RC,,,,,,inpatient,facility,,,4200.77,4200.77,295.98,13000,,4017,,,per diem,,,,,,4200.77,,,fee schedule,,,,,,3570.65,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,20876.4,20876.4,27242.32,1 through 10,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4200.77,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4200.77,,,case rate,,,,,,4200.77,,,case rate,,,,,,4200.77,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4200.77,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,2940.54,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2100.39,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2100.39,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2730.5,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4200.77,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,2940.54,,,percent of total billed charges,,,,,,,,,,,,,,,4200.77,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2982.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2940.54,,,percent of total billed charges,,,,,,2520.46,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,3570.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4200.77,,,percent of total billed charges,,,,,,4200.77,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2520.46,,,percent of total billed charges,,,,,,4200.77,,,fee schedule,,,,,,4200.77,,,fee schedule,,,,,,4200.77,,,fee schedule,,,,,,4200.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4200.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3150.58,,,percent of total billed charges,,,,,,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4200.77,,,percent of total billed charges,,,,,,,,,,,,,,,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4200.77,,,percent of total billed charges,,,,,,1890.35,,,percent of total billed charges,,,,,,,,,,,,,,,4200.77,,,fee schedule,,,,,,,,,,,,,,,4200.77,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4200.77,,,fee schedule,,,,,,,,,,,,,,,4200.77,,,fee schedule,,,,,,,,,,,,,,,2520.46,,,percent of total billed charges,,,,,,4200.77,,,percent of total billed charges,,,,,,2520.46,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3570.65,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC SP W TELEMETRY,21490002,CDM,0214,RC,,,,,,inpatient,facility,,,4023.16,4023.16,295.98,13000,,4017,,,per diem,,,,,,4023.16,,,fee schedule,,,,,,3419.69,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,30081.28,20092.92,71350.14,116,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4023.16,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4023.16,,,case rate,,,,,,4023.16,,,case rate,,,,,,4023.16,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4023.16,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,2816.21,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2011.58,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2011.58,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2615.05,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4023.16,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,2816.21,,,percent of total billed charges,,,,,,,,,,,,,,,4023.16,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,22914,22914,22914,1 through 10,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",2856.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2816.21,,,percent of total billed charges,,,,,,2413.9,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,3419.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4023.16,,,percent of total billed charges,,,,,,4023.16,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2413.9,,,percent of total billed charges,,,,,,4023.16,,,fee schedule,,,,,,4023.16,,,fee schedule,,,,,,4023.16,,,fee schedule,,,,,,4023.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4023.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.37,,,percent of total billed charges,,,,,,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4023.16,,,percent of total billed charges,,,,,,,,,,,,,,,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4023.16,,,percent of total billed charges,,,,,,1810.42,,,percent of total billed charges,,,,,,,,,,,,,,,4023.16,,,fee schedule,,,,,,,,,,,,,,,4023.16,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4023.16,,,fee schedule,,,,,,,,,,,,,,,4023.16,,,fee schedule,,,,,,,,,,,,,,,2413.9,,,percent of total billed charges,,,,,,4023.16,,,percent of total billed charges,,,,,,2413.9,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3419.69,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC PVT  W  TELEMETRY,21490003,CDM,0214,RC,,,,,,inpatient,facility,,,4200.77,4200.77,295.98,13000,,4017,,,per diem,,,,,,4200.77,,,fee schedule,,,,,,3570.65,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4200.77,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4200.77,,,case rate,,,,,,4200.77,,,case rate,,,,,,4200.77,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4200.77,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,2940.54,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2100.39,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2100.39,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2730.5,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4200.77,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,2940.54,,,percent of total billed charges,,,,,,,,,,,,,,,4200.77,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2982.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2940.54,,,percent of total billed charges,,,,,,2520.46,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,3570.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4200.77,,,percent of total billed charges,,,,,,4200.77,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2520.46,,,percent of total billed charges,,,,,,4200.77,,,fee schedule,,,,,,4200.77,,,fee schedule,,,,,,4200.77,,,fee schedule,,,,,,4200.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4200.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3150.58,,,percent of total billed charges,,,,,,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4200.77,,,percent of total billed charges,,,,,,,,,,,,,,,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4200.77,,,percent of total billed charges,,,,,,1890.35,,,percent of total billed charges,,,,,,,,,,,,,,,4200.77,,,fee schedule,,,,,,,,,,,,,,,4200.77,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4200.77,,,fee schedule,,,,,,,,,,,,,,,4200.77,,,fee schedule,,,,,,,,,,,,,,,2520.46,,,percent of total billed charges,,,,,,4200.77,,,percent of total billed charges,,,,,,2520.46,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4200.77,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3570.65,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC ISOLATION W TELEMETRY,21490010,CDM,0214,RC,,,,,,inpatient,facility,,,4540.54,4540.54,295.98,13000,,4017,,,per diem,,,,,,4540.54,,,fee schedule,,,,,,3859.46,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4540.54,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4540.54,,,case rate,,,,,,4540.54,,,case rate,,,,,,4540.54,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4540.54,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,3178.38,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2270.27,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2270.27,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2951.35,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4540.54,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,3178.38,,,percent of total billed charges,,,,,,,,,,,,,,,4540.54,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3223.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3178.38,,,percent of total billed charges,,,,,,2724.32,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,3859.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4540.54,,,percent of total billed charges,,,,,,4540.54,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2724.32,,,percent of total billed charges,,,,,,4540.54,,,fee schedule,,,,,,4540.54,,,fee schedule,,,,,,4540.54,,,fee schedule,,,,,,4540.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3405.4,,,percent of total billed charges,,,,,,4540.54,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4540.54,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4540.54,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4540.54,,,percent of total billed charges,,,,,,,,,,,,,,,4540.54,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4540.54,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4540.54,,,percent of total billed charges,,,,,,2043.24,,,percent of total billed charges,,,,,,,,,,,,,,,4540.54,,,fee schedule,,,,,,,,,,,,,,,4540.54,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4540.54,,,fee schedule,,,,,,,,,,,,,,,4540.54,,,fee schedule,,,,,,,,,,,,,,,2724.32,,,percent of total billed charges,,,,,,4540.54,,,percent of total billed charges,,,,,,2724.32,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4540.54,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4540.54,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3859.46,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC INTERMEDIATE CARE,21490014,CDM,0214,RC,,,,,,inpatient,facility,,,6463.31,6463.31,295.98,13000,,4017,,,per diem,,,,,,6463.31,,,fee schedule,,,,,,5493.81,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,45375.23,22705.94,145462.4,19,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6463.31,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,6463.31,,,case rate,,,,,,6463.31,,,case rate,,,,,,6463.31,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,6463.31,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,4524.32,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3231.66,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3231.66,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,4201.15,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,6463.31,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,4524.32,,,percent of total billed charges,,,,,,,,,,,,,,,6463.31,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",4588.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4524.32,,,percent of total billed charges,,,,,,3877.99,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,5493.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6463.31,,,percent of total billed charges,,,,,,6463.31,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3877.99,,,percent of total billed charges,,,,,,6463.31,,,fee schedule,,,,,,6463.31,,,fee schedule,,,,,,6463.31,,,fee schedule,,,,,,6463.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,6463.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4847.48,,,percent of total billed charges,,,,,,6463.31,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6463.31,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6463.31,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,6463.31,,,percent of total billed charges,,,,,,,,,,,,,,,6463.31,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6463.31,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6463.31,,,percent of total billed charges,,,,,,2908.49,,,percent of total billed charges,,,,,,,,,,,,,,,6463.31,,,fee schedule,,,,,,,,,,,,,,,6463.31,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,6463.31,,,fee schedule,,,,,,,,,,,,,,,6463.31,,,fee schedule,,,,,,,,,,,,,,,3877.99,,,percent of total billed charges,,,,,,6463.31,,,percent of total billed charges,,,,,,3877.99,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,6463.31,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6463.31,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,5493.81,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC KELLER SP W TELEMETRY,21490032,CDM,0214,RC,,,,,,inpatient,facility,,,4023.16,4023.16,295.98,13000,,4017,,,per diem,,,,,,4023.16,,,fee schedule,,,,,,3419.69,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4023.16,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4023.16,,,case rate,,,,,,4023.16,,,case rate,,,,,,4023.16,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4023.16,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,2816.21,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2011.58,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2011.58,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2615.05,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4023.16,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,2816.21,,,percent of total billed charges,,,,,,,,,,,,,,,4023.16,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",2856.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2816.21,,,percent of total billed charges,,,,,,2413.9,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,3419.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4023.16,,,percent of total billed charges,,,,,,4023.16,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2413.9,,,percent of total billed charges,,,,,,4023.16,,,fee schedule,,,,,,4023.16,,,fee schedule,,,,,,4023.16,,,fee schedule,,,,,,4023.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4023.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3017.37,,,percent of total billed charges,,,,,,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4023.16,,,percent of total billed charges,,,,,,,,,,,,,,,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4023.16,,,percent of total billed charges,,,,,,1810.42,,,percent of total billed charges,,,,,,,,,,,,,,,4023.16,,,fee schedule,,,,,,,,,,,,,,,4023.16,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4023.16,,,fee schedule,,,,,,,,,,,,,,,4023.16,,,fee schedule,,,,,,,,,,,,,,,2413.9,,,percent of total billed charges,,,,,,4023.16,,,percent of total billed charges,,,,,,2413.9,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4023.16,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3419.69,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC GRAND SUITE W TELEMETRY,21490033,CDM,0214,RC,,,,,,inpatient,facility,,,5104.24,5104.24,295.98,13000,,4017,,,per diem,,,,,,5104.24,,,fee schedule,,,,,,4338.6,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5104.24,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,5104.24,,,case rate,,,,,,5104.24,,,case rate,,,,,,5104.24,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,5104.24,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,3572.97,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.12,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.12,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3317.76,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,5104.24,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,3572.97,,,percent of total billed charges,,,,,,,,,,,,,,,5104.24,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3624.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3572.97,,,percent of total billed charges,,,,,,3062.54,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,4338.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5104.24,,,percent of total billed charges,,,,,,5104.24,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3062.54,,,percent of total billed charges,,,,,,5104.24,,,fee schedule,,,,,,5104.24,,,fee schedule,,,,,,5104.24,,,fee schedule,,,,,,5104.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,5104.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3828.18,,,percent of total billed charges,,,,,,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5104.24,,,percent of total billed charges,,,,,,,,,,,,,,,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5104.24,,,percent of total billed charges,,,,,,2296.91,,,percent of total billed charges,,,,,,,,,,,,,,,5104.24,,,fee schedule,,,,,,,,,,,,,,,5104.24,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,5104.24,,,fee schedule,,,,,,,,,,,,,,,5104.24,,,fee schedule,,,,,,,,,,,,,,,3062.54,,,percent of total billed charges,,,,,,5104.24,,,percent of total billed charges,,,,,,3062.54,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,4338.6,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC GRAND SUITE  W TELEMETRY,21490034,CDM,0214,RC,,,,,,inpatient,facility,,,5104.24,5104.24,295.98,13000,,4017,,,per diem,,,,,,5104.24,,,fee schedule,,,,,,4338.6,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5104.24,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,5104.24,,,case rate,,,,,,5104.24,,,case rate,,,,,,5104.24,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,5104.24,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,3572.97,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.12,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2552.12,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3317.76,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,5104.24,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,3572.97,,,percent of total billed charges,,,,,,,,,,,,,,,5104.24,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3624.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3572.97,,,percent of total billed charges,,,,,,3062.54,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,4338.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5104.24,,,percent of total billed charges,,,,,,5104.24,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3062.54,,,percent of total billed charges,,,,,,5104.24,,,fee schedule,,,,,,5104.24,,,fee schedule,,,,,,5104.24,,,fee schedule,,,,,,5104.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,5104.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3828.18,,,percent of total billed charges,,,,,,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5104.24,,,percent of total billed charges,,,,,,,,,,,,,,,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5104.24,,,percent of total billed charges,,,,,,2296.91,,,percent of total billed charges,,,,,,,,,,,,,,,5104.24,,,fee schedule,,,,,,,,,,,,,,,5104.24,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,5104.24,,,fee schedule,,,,,,,,,,,,,,,5104.24,,,fee schedule,,,,,,,,,,,,,,,3062.54,,,percent of total billed charges,,,,,,5104.24,,,percent of total billed charges,,,,,,3062.54,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5104.24,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,4338.6,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC VIP PVT W TELEMETRY,21490035,CDM,0214,RC,,,,,,inpatient,facility,,,4563.7,4563.7,295.98,13000,,4017,,,per diem,,,,,,4563.7,,,fee schedule,,,,,,3879.14,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4563.7,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4563.7,,,case rate,,,,,,4563.7,,,case rate,,,,,,4563.7,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4563.7,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,3194.59,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2281.85,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2281.85,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2966.41,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4563.7,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,3194.59,,,percent of total billed charges,,,,,,,,,,,,,,,4563.7,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3240.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3194.59,,,percent of total billed charges,,,,,,2738.22,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,3879.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4563.7,,,percent of total billed charges,,,,,,4563.7,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2738.22,,,percent of total billed charges,,,,,,4563.7,,,fee schedule,,,,,,4563.7,,,fee schedule,,,,,,4563.7,,,fee schedule,,,,,,4563.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4563.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3422.77,,,percent of total billed charges,,,,,,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4563.7,,,percent of total billed charges,,,,,,,,,,,,,,,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4563.7,,,percent of total billed charges,,,,,,2053.66,,,percent of total billed charges,,,,,,,,,,,,,,,4563.7,,,fee schedule,,,,,,,,,,,,,,,4563.7,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4563.7,,,fee schedule,,,,,,,,,,,,,,,4563.7,,,fee schedule,,,,,,,,,,,,,,,2738.22,,,percent of total billed charges,,,,,,4563.7,,,percent of total billed charges,,,,,,2738.22,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3879.14,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC VIP PVT  W  TELEMETRY,21490036,CDM,0214,RC,,,,,,inpatient,facility,,,4563.7,4563.7,295.98,13000,,4017,,,per diem,,,,,,4563.7,,,fee schedule,,,,,,3879.14,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4563.7,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4563.7,,,case rate,,,,,,4563.7,,,case rate,,,,,,4563.7,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4563.7,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,3194.59,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2281.85,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2281.85,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2966.41,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4563.7,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,3194.59,,,percent of total billed charges,,,,,,,,,,,,,,,4563.7,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3240.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3194.59,,,percent of total billed charges,,,,,,2738.22,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,3879.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4563.7,,,percent of total billed charges,,,,,,4563.7,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2738.22,,,percent of total billed charges,,,,,,4563.7,,,fee schedule,,,,,,4563.7,,,fee schedule,,,,,,4563.7,,,fee schedule,,,,,,4563.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4563.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3422.77,,,percent of total billed charges,,,,,,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4563.7,,,percent of total billed charges,,,,,,,,,,,,,,,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4563.7,,,percent of total billed charges,,,,,,2053.66,,,percent of total billed charges,,,,,,,,,,,,,,,4563.7,,,fee schedule,,,,,,,,,,,,,,,4563.7,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4563.7,,,fee schedule,,,,,,,,,,,,,,,4563.7,,,fee schedule,,,,,,,,,,,,,,,2738.22,,,percent of total billed charges,,,,,,4563.7,,,percent of total billed charges,,,,,,2738.22,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4563.7,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,3879.14,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC VIP SUITE W TELEMETRY,21490037,CDM,0214,RC,,,,,,inpatient,facility,,,4795.36,4795.36,295.98,13000,,4017,,,per diem,,,,,,4795.36,,,fee schedule,,,,,,4076.06,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4795.36,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4795.36,,,case rate,,,,,,4795.36,,,case rate,,,,,,4795.36,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4795.36,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,3356.75,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2397.68,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2397.68,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3116.98,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4795.36,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,3356.75,,,percent of total billed charges,,,,,,,,,,,,,,,4795.36,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3404.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3356.75,,,percent of total billed charges,,,,,,2877.22,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,4076.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4795.36,,,percent of total billed charges,,,,,,4795.36,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2877.22,,,percent of total billed charges,,,,,,4795.36,,,fee schedule,,,,,,4795.36,,,fee schedule,,,,,,4795.36,,,fee schedule,,,,,,4795.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4795.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3596.52,,,percent of total billed charges,,,,,,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4795.36,,,percent of total billed charges,,,,,,,,,,,,,,,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4795.36,,,percent of total billed charges,,,,,,2157.91,,,percent of total billed charges,,,,,,,,,,,,,,,4795.36,,,fee schedule,,,,,,,,,,,,,,,4795.36,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4795.36,,,fee schedule,,,,,,,,,,,,,,,4795.36,,,fee schedule,,,,,,,,,,,,,,,2877.22,,,percent of total billed charges,,,,,,4795.36,,,percent of total billed charges,,,,,,2877.22,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,4076.06,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC VIP SUITE  W  TELEMETRY,21490038,CDM,0214,RC,,,,,,inpatient,facility,,,4795.36,4795.36,295.98,13000,,4017,,,per diem,,,,,,4795.36,,,fee schedule,,,,,,4076.06,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4795.36,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,4795.36,,,case rate,,,,,,4795.36,,,case rate,,,,,,4795.36,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4795.36,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,3356.75,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2397.68,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,2397.68,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3116.98,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,4795.36,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,3356.75,,,percent of total billed charges,,,,,,,,,,,,,,,4795.36,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",3404.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3356.75,,,percent of total billed charges,,,,,,2877.22,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,4076.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4795.36,,,percent of total billed charges,,,,,,4795.36,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2877.22,,,percent of total billed charges,,,,,,4795.36,,,fee schedule,,,,,,4795.36,,,fee schedule,,,,,,4795.36,,,fee schedule,,,,,,4795.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,4795.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3596.52,,,percent of total billed charges,,,,,,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4795.36,,,percent of total billed charges,,,,,,,,,,,,,,,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4795.36,,,percent of total billed charges,,,,,,2157.91,,,percent of total billed charges,,,,,,,,,,,,,,,4795.36,,,fee schedule,,,,,,,,,,,,,,,4795.36,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,4795.36,,,fee schedule,,,,,,,,,,,,,,,4795.36,,,fee schedule,,,,,,,,,,,,,,,2877.22,,,percent of total billed charges,,,,,,4795.36,,,percent of total billed charges,,,,,,2877.22,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4795.36,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,4076.06,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
HC ISOLATION W INTERMEDIATE CARE,21491617,CDM,0214,RC,,,,,,inpatient,facility,,,6131.27,6131.27,295.98,13000,,4017,,,per diem,,,,,,6131.27,,,fee schedule,,,,,,5211.58,,,percent of total billed charges,,,,,,,,,,,,,,,2289,,,per diem,,,,,,2169.23,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 95.00% End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,295.98,,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ,other,,,,0,Interim Value: PassThru Per Diem   Procedure Lookup Tables:     [PASSTHRU PER DIEM]       1st procedure payable at 100% of base price in table.    Procedures are sorted by table amount prior to applying multipliers.    Any subsequent procedures are not payable. Interim Value: IP PASSTHROUGH AMOUNT   Formula:= ( Days in Visit * PassThru Per Diem ) Medicare I/P Reimbursement:    230.625% of Medicare Reimbursement (All acute components are 230.625%)  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% Formula:= ( Current Amount   ) + ( IP PASSTHROUGH AMOUNT * 2.30625 ) ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.27,,,case rate,,,,,,,,,,,,,,,,,,,,,,,,6131.27,,,case rate,,,,,,6131.27,,,case rate,,,,,,6131.27,,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ,other,,,,0,100.00 % of Gross Charges Manual Review/Entry: Flag for review : Claim did not contain     rehabilitation codes - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,6131.27,,,case rate,,,,,,1960,,,per diem,,,,,,1475,,,per diem,,,,,,4291.89,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 85.00%  Operating Outliers: 85.00%  Operating DSH: 85.00%  Operating IME: 0.00%  Federal Capital: 85.00%  Capital Outliers: 85.00%  Capital DSH: 85.00%  Capital IME: 85.00%  Pass-Through: 85.00%   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  70.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3065.64,,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    120.00% of Medicare Reimbursement (All acute components are 120.00%)  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3065.64,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ,other,,,,0,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 102.00%  Operating Outliers: 102.00%  Operating DSH: 102.00%  Operating IME: 0.00%  Federal Capital: 102.00%  Capital Outliers: 102.00%  Capital DSH: 102.00%  Capital IME: 102.00%  Pass-Through: 102.00%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 100034   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  50.00 % of Gross Charges Adjusted ; Zero instances of the item or service in the 15 months prior to posting the file.,3985.33,,,percent of total billed charges,,,,,,,,,,,,,,,2055.06,,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE",other,,,,0,"$2,283.40 Per Diem  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.",500,,,per diem,,,,,,6131.27,,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3706,,,per diem,,,,,,4291.89,,,percent of total billed charges,,,,,,,,,,,,,,,6131.27,,,percent of total billed charges,,,,,,12090,,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ",other,,,,0,"$13,000.00 Per Diem  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.",4353.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4291.89,,,percent of total billed charges,,,,,,3678.76,,,percent of total billed charges,,,,,,4000,,,per diem,,,,,,,,,,,,,,,5211.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6131.27,,,percent of total billed charges,,,,,,6131.27,,,percent of total billed charges,,,,,,1843,,,per diem,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3678.76,,,percent of total billed charges,,,,,,6131.27,,,fee schedule,,,,,,6131.27,,,fee schedule,,,,,,6131.27,,,fee schedule,,,,,,6131.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,665,,,per diem,,,,,,6131.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4598.45,,,percent of total billed charges,,,,,,6131.27,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6131.27,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6131.27,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,6131.27,,,percent of total billed charges,,,,,,,,,,,,,,,6131.27,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6131.27,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6131.27,,,percent of total billed charges,,,,,,2759.07,,,percent of total billed charges,,,,,,,,,,,,,,,6131.27,,,fee schedule,,,,,,,,,,,,,,,6131.27,,,fee schedule,,,,,,650,,,per diem,,,,,,,,,,,,,,,6131.27,,,fee schedule,,,,,,,,,,,,,,,6131.27,,,fee schedule,,,,,,,,,,,,,,,3678.76,,,percent of total billed charges,,,,,,6131.27,,,percent of total billed charges,,,,,,3678.76,,,percent of total billed charges,,,,,,4010,,,per diem,,,,,,,,,,,,,,,6566,,,per diem,,,,,,6131.27,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : No other IP discounts have     been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6131.27,,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Gross Charges Adjusted Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,500,,,per diem,,,,,,5211.58,,,percent of total billed charges,,,,,,13000,,,per diem,,,,,
STENT URET ENDOPYEL RETROMAX PLUS 7 X 14 X 26,21497,CDM,0278,RC,,,,,,inpatient,facility,,,371.96,371.96,167.38,371.96,,,,,,,,,,,,,,,,,,,,316.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297.57,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,278.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,224.85,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",264.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,260.37,,,percent of total billed charges,,,,,,223.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,316.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,371.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,167.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.17,,,percent of total billed charges,,,,,,241.77,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STENT URET ENDOPYEL RETROMAX PLUS 7 X 14 X 26,21497,CDM,0278,RC,,,,,,outpatient,facility,,,371.96,371.96,70.67,371.96,,241.77,,,percent of total billed charges,,,,,,,,,,,,,,,316.17,,,percent of total billed charges,,,,,,111.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,174.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.58,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,70.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,70.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,204.58,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,204.58,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,204.58,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,278.97,,,percent of total billed charges,,,,,,260.37,,,percent of total billed charges,,,,,,260.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,241.77,,,percent of total billed charges,,,,,,89.27,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,371.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,156.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",260.37,,,percent of total billed charges,,,,,,,,,,,,,,,371.96,,,percent of total billed charges,,,,,,259.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,264.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,260.37,,,percent of total billed charges,,,,,,223.18,,,percent of total billed charges,,,,,,167.38,,,percent of total billed charges,,,,,,,,,,,,,,,316.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.96,,,percent of total billed charges,,,,,,371.96,,,percent of total billed charges,,,,,,159.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,371.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,371.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.97,,,percent of total billed charges,,,,,,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,371.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,371.96,,,percent of total billed charges,,,,,,167.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.96,,,fee schedule,,,,,,371.96,,,percent of total billed charges,,,,,,371.96,,,percent of total billed charges,,,,,,371.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,371.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,316.17,,,percent of total billed charges,,,,,,278.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SET INFUS PULSE SPRAY 5FR 135 X 20  i,21499,CDM,0272,RC,,,,,,inpatient,facility,,,945,945,425.25,945,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,614.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,670.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,661.5,,,percent of total billed charges,,,,,,567,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,
SET INFUS PULSE SPRAY 5FR 135 X 20  i,21499,CDM,0272,RC,,,,,,outpatient,facility,,,945,945,129.72,1016,,614.25,,,percent of total billed charges,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,283.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,444.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,708.76,,,percent of total billed charges,,,,,,661.5,,,percent of total billed charges,,,,,,661.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,614.25,,,percent of total billed charges,,,,,,226.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",637.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,945,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,396.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",661.5,,,percent of total billed charges,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,659.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,670.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,661.5,,,percent of total billed charges,,,,,,567,,,percent of total billed charges,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,406.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,,percent of total billed charges,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,fee schedule,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,453.6,,,percent of total billed charges,,,,,,,,,,,,,,,557.55,,,percent of total billed charges,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,803.25,,,percent of total billed charges,,,,,,708.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SET INFUS PULSE SPRAY 5FR 135 X 30  i,21500,CDM,0272,RC,,,,,,inpatient,facility,,,945,945,425.25,945,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,614.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,670.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,661.5,,,percent of total billed charges,,,,,,567,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,
SET INFUS PULSE SPRAY 5FR 135 X 30  i,21500,CDM,0272,RC,,,,,,outpatient,facility,,,945,945,129.72,1016,,614.25,,,percent of total billed charges,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,283.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,444.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,708.76,,,percent of total billed charges,,,,,,661.5,,,percent of total billed charges,,,,,,661.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,614.25,,,percent of total billed charges,,,,,,226.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",637.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,945,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,396.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",661.5,,,percent of total billed charges,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,659.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,670.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,661.5,,,percent of total billed charges,,,,,,567,,,percent of total billed charges,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,803.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,406.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,945,,,percent of total billed charges,,,,,,425.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,708.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945,,,fee schedule,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,945,,,percent of total billed charges,,,,,,453.6,,,percent of total billed charges,,,,,,,,,,,,,,,557.55,,,percent of total billed charges,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,945,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,803.25,,,percent of total billed charges,,,,,,708.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS LNG TH 4.0 X 28,21548,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS LNG TH 4.0 X 28,21548,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 26 X 10 X 50,21551,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 26 X 10 X 50,21551,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 100 50MM,21552,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 100 50MM,21552,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SET NASAL BILIARY DRAINAGE,21573,CDM,0272,RC,,,,,,inpatient,facility,,,455,455,204.75,455,,,,,,,,,,,,,,,,,,,,386.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,295.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,318.5,,,percent of total billed charges,,,,,,273,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,386.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,455,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,204.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.75,,,percent of total billed charges,,,,,,,,,,,,,,
SET NASAL BILIARY DRAINAGE,21573,CDM,0272,RC,,,,,,outpatient,facility,,,455,455,86.45,1016,,295.75,,,percent of total billed charges,,,,,,,,,,,,,,,386.75,,,percent of total billed charges,,,,,,136.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,213.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,86.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,86.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,341.26,,,percent of total billed charges,,,,,,318.5,,,percent of total billed charges,,,,,,318.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,295.75,,,percent of total billed charges,,,,,,109.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",307.12,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,455,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,191.1,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",318.5,,,percent of total billed charges,,,,,,,,,,,,,,,455,,,percent of total billed charges,,,,,,317.36,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,323.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,318.5,,,percent of total billed charges,,,,,,273,,,percent of total billed charges,,,,,,204.75,,,percent of total billed charges,,,,,,,,,,,,,,,386.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455,,,percent of total billed charges,,,,,,455,,,percent of total billed charges,,,,,,195.65,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,455,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,455,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.25,,,percent of total billed charges,,,,,,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,455,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,455,,,percent of total billed charges,,,,,,204.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,455,,,fee schedule,,,,,,455,,,percent of total billed charges,,,,,,455,,,percent of total billed charges,,,,,,455,,,percent of total billed charges,,,,,,218.4,,,percent of total billed charges,,,,,,,,,,,,,,,268.45,,,percent of total billed charges,,,,,,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,455,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,386.75,,,percent of total billed charges,,,,,,341.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DRAIN FLEXIMA ADP REG 8FR 20CM,21623,CDM,0272,RC,,,,,,inpatient,facility,,,256.58,256.58,115.46,256.58,,,,,,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.61,,,percent of total billed charges,,,,,,153.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DRAIN FLEXIMA ADP REG 8FR 20CM,21623,CDM,0272,RC,,,,,,outpatient,facility,,,256.58,256.58,48.75,1016,,166.78,,,percent of total billed charges,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,76.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,48.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,192.43,,,percent of total billed charges,,,,,,179.61,,,percent of total billed charges,,,,,,179.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.78,,,percent of total billed charges,,,,,,61.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",173.19,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.58,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.76,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.61,,,percent of total billed charges,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,178.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.61,,,percent of total billed charges,,,,,,153.95,,,percent of total billed charges,,,,,,115.46,,,percent of total billed charges,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,256.58,,,percent of total billed charges,,,,,,110.33,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.44,,,percent of total billed charges,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.58,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.58,,,percent of total billed charges,,,,,,115.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,fee schedule,,,,,,256.58,,,percent of total billed charges,,,,,,256.58,,,percent of total billed charges,,,,,,256.58,,,percent of total billed charges,,,,,,123.16,,,percent of total billed charges,,,,,,,,,,,,,,,151.38,,,percent of total billed charges,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.09,,,percent of total billed charges,,,,,,192.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DRAIN FLEXIMA ADP REG 10FR 25CM,21624,CDM,0272,RC,,,,,,inpatient,facility,,,256.58,256.58,115.46,256.58,,,,,,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.61,,,percent of total billed charges,,,,,,153.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DRAIN FLEXIMA ADP REG 10FR 25CM,21624,CDM,0272,RC,,,,,,outpatient,facility,,,256.58,256.58,48.75,1016,,166.78,,,percent of total billed charges,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,76.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,48.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,192.43,,,percent of total billed charges,,,,,,179.61,,,percent of total billed charges,,,,,,179.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.78,,,percent of total billed charges,,,,,,61.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",173.19,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.58,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.76,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.61,,,percent of total billed charges,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,178.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.61,,,percent of total billed charges,,,,,,153.95,,,percent of total billed charges,,,,,,115.46,,,percent of total billed charges,,,,,,,,,,,,,,,218.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,256.58,,,percent of total billed charges,,,,,,110.33,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.44,,,percent of total billed charges,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.58,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.58,,,percent of total billed charges,,,,,,115.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.58,,,fee schedule,,,,,,256.58,,,percent of total billed charges,,,,,,256.58,,,percent of total billed charges,,,,,,256.58,,,percent of total billed charges,,,,,,123.16,,,percent of total billed charges,,,,,,,,,,,,,,,151.38,,,percent of total billed charges,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.09,,,percent of total billed charges,,,,,,192.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
COUNTERSINK SYN CANN 3.0,21629,CDM,0272,RC,,,,,,inpatient,facility,,,1164.24,1164.24,523.91,1164.24,,,,,,,,,,,,,,,,,,,,989.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,756.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,826.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,814.97,,,percent of total billed charges,,,,,,698.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,989.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1164.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,523.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,989.6,,,percent of total billed charges,,,,,,,,,,,,,,
COUNTERSINK SYN CANN 3.0,21629,CDM,0272,RC,,,,,,outpatient,facility,,,1164.24,1164.24,129.72,1164.24,,756.76,,,percent of total billed charges,,,,,,,,,,,,,,,989.6,,,percent of total billed charges,,,,,,349.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,547.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,221.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,221.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,873.18,,,percent of total billed charges,,,,,,814.97,,,percent of total billed charges,,,,,,814.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,756.76,,,percent of total billed charges,,,,,,279.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",785.86,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1164.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,488.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",814.97,,,percent of total billed charges,,,,,,,,,,,,,,,1164.24,,,percent of total billed charges,,,,,,812.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,826.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,814.97,,,percent of total billed charges,,,,,,698.54,,,percent of total billed charges,,,,,,523.91,,,percent of total billed charges,,,,,,,,,,,,,,,989.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.24,,,percent of total billed charges,,,,,,1164.24,,,percent of total billed charges,,,,,,500.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1164.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.18,,,percent of total billed charges,,,,,,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1164.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1164.24,,,percent of total billed charges,,,,,,523.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1164.24,,,fee schedule,,,,,,1164.24,,,percent of total billed charges,,,,,,1164.24,,,percent of total billed charges,,,,,,1164.24,,,percent of total billed charges,,,,,,558.84,,,percent of total billed charges,,,,,,,,,,,,,,,686.9,,,percent of total billed charges,,,,,,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1164.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,989.6,,,percent of total billed charges,,,,,,873.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 14,21642,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 14,21642,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 15,21643,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 15,21643,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 16,21644,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 16,21644,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 17,21645,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 17,21645,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 18,21646,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 18,21646,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 20,21647,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 20,21647,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 19,21648,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 19,21648,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 21,21649,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 21,21649,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 22,21650,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 22,21650,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STENT URET CONTOUR 7.0FR 22CM  i,21662,CDM,0278,RC,,,,,,inpatient,facility,,,215.46,215.46,96.96,215.46,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.37,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,161.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.25,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.82,,,percent of total billed charges,,,,,,129.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,140.05,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STENT URET CONTOUR 7.0FR 22CM  i,21662,CDM,0278,RC,,,,,,outpatient,facility,,,215.46,215.46,40.94,215.46,,140.05,,,percent of total billed charges,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,64.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,101.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,40.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,40.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,118.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.6,,,percent of total billed charges,,,,,,150.82,,,percent of total billed charges,,,,,,150.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,140.05,,,percent of total billed charges,,,,,,51.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,215.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,90.49,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",150.82,,,percent of total billed charges,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,150.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,152.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.82,,,percent of total billed charges,,,,,,129.28,,,percent of total billed charges,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,183.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,92.65,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.6,,,percent of total billed charges,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,215.46,,,percent of total billed charges,,,,,,96.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,,fee schedule,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,215.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,215.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,183.14,,,percent of total billed charges,,,,,,161.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE AMPLZ ULT STIFF FLEX .035 X 5 X 145  i,21663,CDM,0272,RC,,,,,,inpatient,facility,,,142.48,142.48,64.12,142.48,,,,,,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,99.74,,,percent of total billed charges,,,,,,85.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,64.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE AMPLZ ULT STIFF FLEX .035 X 5 X 145  i,21663,CDM,0272,RC,,,,,,outpatient,facility,,,142.48,142.48,27.07,1016,,92.61,,,percent of total billed charges,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,42.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,27.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,27.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,106.86,,,percent of total billed charges,,,,,,99.74,,,percent of total billed charges,,,,,,99.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,92.61,,,percent of total billed charges,,,,,,34.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",96.17,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,142.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,59.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",99.74,,,percent of total billed charges,,,,,,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,99.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,101.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,99.74,,,percent of total billed charges,,,,,,85.49,,,percent of total billed charges,,,,,,64.12,,,percent of total billed charges,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,142.48,,,percent of total billed charges,,,,,,61.27,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,142.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,142.48,,,percent of total billed charges,,,,,,64.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,,fee schedule,,,,,,142.48,,,percent of total billed charges,,,,,,142.48,,,percent of total billed charges,,,,,,142.48,,,percent of total billed charges,,,,,,68.39,,,percent of total billed charges,,,,,,,,,,,,,,,84.06,,,percent of total billed charges,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,121.11,,,percent of total billed charges,,,,,,106.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T LOCK 5.0 X 65,21684,CDM,0278,RC,,,,,,inpatient,facility,,,172.7,172.7,77.72,172.7,,,,,,,,,,,,,,,,,,,,146.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,129.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.4,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",122.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,120.89,,,percent of total billed charges,,,,,,103.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,146.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,172.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,77.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.79,,,percent of total billed charges,,,,,,112.26,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T LOCK 5.0 X 65,21684,CDM,0278,RC,,,,,,outpatient,facility,,,172.7,172.7,32.81,172.7,,112.25,,,percent of total billed charges,,,,,,,,,,,,,,,146.79,,,percent of total billed charges,,,,,,51.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,81.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.98,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,94.98,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,94.98,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.98,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,129.52,,,percent of total billed charges,,,,,,120.89,,,percent of total billed charges,,,,,,120.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,112.25,,,percent of total billed charges,,,,,,41.45,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,172.7,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,72.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",120.89,,,percent of total billed charges,,,,,,,,,,,,,,,172.7,,,percent of total billed charges,,,,,,120.46,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,122.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,120.89,,,percent of total billed charges,,,,,,103.62,,,percent of total billed charges,,,,,,77.72,,,percent of total billed charges,,,,,,,,,,,,,,,146.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.7,,,percent of total billed charges,,,,,,172.7,,,percent of total billed charges,,,,,,74.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,172.7,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,172.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.52,,,percent of total billed charges,,,,,,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,172.7,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,172.7,,,percent of total billed charges,,,,,,77.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.7,,,fee schedule,,,,,,172.7,,,percent of total billed charges,,,,,,172.7,,,percent of total billed charges,,,,,,172.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,172.7,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,146.79,,,percent of total billed charges,,,,,,129.53,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CANNULA DLP VENOUS RT ANGL MET TIP SS 28FR  i,21709,CDM,0272,RC,,,,,,inpatient,facility,,,153.97,153.97,69.29,153.97,,,,,,,,,,,,,,,,,,,,130.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,107.78,,,percent of total billed charges,,,,,,92.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,130.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,153.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,69.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.87,,,percent of total billed charges,,,,,,,,,,,,,,
CANNULA DLP VENOUS RT ANGL MET TIP SS 28FR  i,21709,CDM,0272,RC,,,,,,outpatient,facility,,,153.97,153.97,29.25,1016,,100.08,,,percent of total billed charges,,,,,,,,,,,,,,,130.87,,,percent of total billed charges,,,,,,46.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,72.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,29.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,115.48,,,percent of total billed charges,,,,,,107.78,,,percent of total billed charges,,,,,,107.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,100.08,,,percent of total billed charges,,,,,,36.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",103.93,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,153.97,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,64.67,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",107.78,,,percent of total billed charges,,,,,,,,,,,,,,,153.97,,,percent of total billed charges,,,,,,107.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,109.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,107.78,,,percent of total billed charges,,,,,,92.38,,,percent of total billed charges,,,,,,69.29,,,percent of total billed charges,,,,,,,,,,,,,,,130.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.97,,,percent of total billed charges,,,,,,153.97,,,percent of total billed charges,,,,,,66.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,153.97,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,153.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.48,,,percent of total billed charges,,,,,,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,153.97,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,153.97,,,percent of total billed charges,,,,,,69.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.97,,,fee schedule,,,,,,153.97,,,percent of total billed charges,,,,,,153.97,,,percent of total billed charges,,,,,,153.97,,,percent of total billed charges,,,,,,73.91,,,percent of total billed charges,,,,,,,,,,,,,,,90.84,,,percent of total billed charges,,,,,,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,153.97,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,130.87,,,percent of total billed charges,,,,,,115.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 23,21718,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 23,21718,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 24,21719,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 24,21719,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 25,21720,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 25,21720,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 26,21721,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 26,21721,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 27,21722,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 27,21722,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 28,21723,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 28,21723,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 29,21724,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 29,21724,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 30,21725,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 30,21725,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 32,21726,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 32,21726,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 34,21727,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 34,21727,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 36,21728,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 36,21728,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 38,21729,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 38,21729,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI SHRT TH 3.0 X 40,21730,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI SHRT TH 3.0 X 40,21730,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 14,21731,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 14,21731,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 15,21732,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 15,21732,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 16,21733,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 16,21733,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 17,21734,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 17,21734,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 18,21735,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 18,21735,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 19,21736,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 19,21736,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 20,21737,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 20,21737,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 21,21738,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 21,21738,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 22,21739,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 22,21739,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 23,21740,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 23,21740,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 24,21741,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 24,21741,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 25,21742,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 25,21742,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 26,21743,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 26,21743,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 27,21744,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 27,21744,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 28,21745,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 28,21745,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 29,21746,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 29,21746,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 30,21747,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 30,21747,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 32,21748,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 32,21748,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 34,21749,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 34,21749,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 36,21750,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 36,21750,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 38,21751,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 38,21751,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI LNG TH 3.0 X 40,21752,CDM,0278,RC,,,,,,inpatient,facility,,,354.96,354.96,159.73,354.96,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,266.22,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.57,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,230.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI LNG TH 3.0 X 40,21752,CDM,0278,RC,,,,,,outpatient,facility,,,354.96,354.96,67.44,354.96,,230.72,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,106.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,266.22,,,percent of total billed charges,,,,,,248.47,,,percent of total billed charges,,,,,,248.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,230.72,,,percent of total billed charges,,,,,,85.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,354.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.08,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.47,,,percent of total billed charges,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,247.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,252.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.47,,,percent of total billed charges,,,,,,212.98,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,301.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,152.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.96,,,percent of total billed charges,,,,,,159.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,266.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,fee schedule,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,354.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.72,,,percent of total billed charges,,,,,,266.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WASHER SYN THREAD SCR 3.0MM,21753,CDM,0278,RC,,,,,,inpatient,facility,,,218.16,218.16,98.17,218.16,,,,,,,,,,,,,,,,,,,,185.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,163.62,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.88,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",154.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,152.71,,,percent of total billed charges,,,,,,130.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,185.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,218.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,98.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.44,,,percent of total billed charges,,,,,,141.8,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WASHER SYN THREAD SCR 3.0MM,21753,CDM,0278,RC,,,,,,outpatient,facility,,,218.16,218.16,41.45,218.16,,141.8,,,percent of total billed charges,,,,,,,,,,,,,,,185.44,,,percent of total billed charges,,,,,,65.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,102.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.99,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,41.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,119.99,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,119.99,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,119.99,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,163.62,,,percent of total billed charges,,,,,,152.71,,,percent of total billed charges,,,,,,152.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,141.8,,,percent of total billed charges,,,,,,52.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,218.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,91.63,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",152.71,,,percent of total billed charges,,,,,,,,,,,,,,,218.16,,,percent of total billed charges,,,,,,152.17,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,154.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,152.71,,,percent of total billed charges,,,,,,130.9,,,percent of total billed charges,,,,,,98.17,,,percent of total billed charges,,,,,,,,,,,,,,,185.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.16,,,percent of total billed charges,,,,,,218.16,,,percent of total billed charges,,,,,,93.81,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,218.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,218.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.62,,,percent of total billed charges,,,,,,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,218.16,,,percent of total billed charges,,,,,,98.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,163.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.16,,,fee schedule,,,,,,218.16,,,percent of total billed charges,,,,,,218.16,,,percent of total billed charges,,,,,,218.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,218.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,185.44,,,percent of total billed charges,,,,,,163.62,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WASHER SYN TI 6.5MM,21754,CDM,0278,RC,,,,,,inpatient,facility,,,46.8,46.8,21.06,46.8,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,35.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.29,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,30.42,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WASHER SYN TI 6.5MM,21754,CDM,0278,RC,,,,,,outpatient,facility,,,46.8,46.8,8.89,138.8,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,14.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,25.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,25.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,35.1,,,percent of total billed charges,,,,,,32.76,,,percent of total billed charges,,,,,,32.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,11.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,46.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.76,,,percent of total billed charges,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,32.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,20.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,fee schedule,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.78,,,percent of total billed charges,,,,,,35.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE SYN TH 1.1 X 150 F CANN SCREW 3.0MM,21755,CDM,0272,RC,,,,,,inpatient,facility,,,83.16,83.16,37.42,83.16,,,,,,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.21,,,percent of total billed charges,,,,,,49.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE SYN TH 1.1 X 150 F CANN SCREW 3.0MM,21755,CDM,0272,RC,,,,,,outpatient,facility,,,83.16,83.16,15.8,1016,,54.05,,,percent of total billed charges,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,24.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,39.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,15.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,62.37,,,percent of total billed charges,,,,,,58.21,,,percent of total billed charges,,,,,,58.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,54.05,,,percent of total billed charges,,,,,,19.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",56.13,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,83.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.93,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",58.21,,,percent of total billed charges,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,59.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.21,,,percent of total billed charges,,,,,,49.9,,,percent of total billed charges,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,70.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,83.16,,,percent of total billed charges,,,,,,35.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,83.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,83.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,83.16,,,percent of total billed charges,,,,,,37.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.16,,,fee schedule,,,,,,83.16,,,percent of total billed charges,,,,,,83.16,,,percent of total billed charges,,,,,,83.16,,,percent of total billed charges,,,,,,39.92,,,percent of total billed charges,,,,,,,,,,,,,,,49.06,,,percent of total billed charges,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,83.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.69,,,percent of total billed charges,,,,,,62.37,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE SYN N TH SPADE 1.1 X 150,21756,CDM,0272,RC,,,,,,inpatient,facility,,,78.12,78.12,35.15,78.12,,,,,,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,,,,46.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE SYN N TH SPADE 1.1 X 150,21756,CDM,0272,RC,,,,,,outpatient,facility,,,78.12,78.12,14.84,1016,,50.78,,,percent of total billed charges,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,23.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,58.59,,,percent of total billed charges,,,,,,54.68,,,percent of total billed charges,,,,,,54.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,50.78,,,percent of total billed charges,,,,,,18.75,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",52.73,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,78.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,32.81,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",54.68,,,percent of total billed charges,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,54.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,55.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,,,,46.87,,,percent of total billed charges,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,78.12,,,percent of total billed charges,,,,,,33.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,78.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,78.12,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,78.12,,,percent of total billed charges,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,,fee schedule,,,,,,78.12,,,percent of total billed charges,,,,,,78.12,,,percent of total billed charges,,,,,,78.12,,,percent of total billed charges,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,46.09,,,percent of total billed charges,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,66.4,,,percent of total billed charges,,,,,,58.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE EAR DONALDSON SOFT VENT 1.14 ID  i,21764,CDM,0278,RC,,,,,,inpatient,facility,,,24.93,24.93,11.22,24.93,,,,,,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,18.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.07,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",17.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,14.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,24.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,16.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
TUBE EAR DONALDSON SOFT VENT 1.14 ID  i,21764,CDM,0278,RC,,,,,,outpatient,facility,,,24.93,24.93,4.74,138.8,,16.2,,,percent of total billed charges,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,7.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,11.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.71,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.71,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.71,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,13.71,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.7,,,percent of total billed charges,,,,,,17.45,,,percent of total billed charges,,,,,,17.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,16.2,,,percent of total billed charges,,,,,,5.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,24.93,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,10.47,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",17.45,,,percent of total billed charges,,,,,,,,,,,,,,,24.93,,,percent of total billed charges,,,,,,17.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,17.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,17.45,,,percent of total billed charges,,,,,,14.96,,,percent of total billed charges,,,,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,21.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.93,,,percent of total billed charges,,,,,,24.93,,,percent of total billed charges,,,,,,10.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,24.93,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,24.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.7,,,percent of total billed charges,,,,,,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.93,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24.93,,,percent of total billed charges,,,,,,11.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.93,,,fee schedule,,,,,,24.93,,,percent of total billed charges,,,,,,24.93,,,percent of total billed charges,,,,,,24.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,24.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,21.19,,,percent of total billed charges,,,,,,18.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE EAR ARMSTRONG GROMMET.045  i,21765,CDM,0278,RC,,,,,,inpatient,facility,,,36.94,36.94,16.62,36.94,,,,,,,,,,,,,,,,,,,,31.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,27.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.33,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",26.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.86,,,percent of total billed charges,,,,,,22.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,31.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,36.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.4,,,percent of total billed charges,,,,,,24.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
TUBE EAR ARMSTRONG GROMMET.045  i,21765,CDM,0278,RC,,,,,,outpatient,facility,,,36.94,36.94,7.02,138.8,,24.01,,,percent of total billed charges,,,,,,,,,,,,,,,31.4,,,percent of total billed charges,,,,,,11.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,20.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,20.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,20.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,27.7,,,percent of total billed charges,,,,,,25.86,,,percent of total billed charges,,,,,,25.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,24.01,,,percent of total billed charges,,,,,,8.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,36.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,15.51,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",25.86,,,percent of total billed charges,,,,,,,,,,,,,,,36.94,,,percent of total billed charges,,,,,,25.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,26.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.86,,,percent of total billed charges,,,,,,22.16,,,percent of total billed charges,,,,,,16.62,,,percent of total billed charges,,,,,,,,,,,,,,,31.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.94,,,percent of total billed charges,,,,,,36.94,,,percent of total billed charges,,,,,,15.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,36.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,36.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.7,,,percent of total billed charges,,,,,,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.94,,,percent of total billed charges,,,,,,16.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.94,,,fee schedule,,,,,,36.94,,,percent of total billed charges,,,,,,36.94,,,percent of total billed charges,,,,,,36.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,36.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,31.4,,,percent of total billed charges,,,,,,27.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEAD MED CAPSURE SP NOVUS 52CM 5092,21790,CDM,0275,RC,,,,,,inpatient,facility,,,850,850,382.5,850,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,
LEAD MED CAPSURE SP NOVUS 52CM 5092,21790,CDM,0275,RC,,,,,,outpatient,facility,,,850,850,129.72,850,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,255,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637.5,,,percent of total billed charges,,,,,,595,,,percent of total billed charges,,,,,,595,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,850,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,592.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,850,,,fee schedule,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,722.5,,,percent of total billed charges,,,,,,637.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 28 X 10 X 56,21793,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 28 X 10 X 56,21793,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC CANN 2.7 X 160,21794,CDM,0272,RC,,,,,,inpatient,facility,,,1159.2,1159.2,521.64,1159.2,,,,,,,,,,,,,,,,,,,,985.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,869.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,753.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,823.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,811.44,,,percent of total billed charges,,,,,,695.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,985.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1159.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,869.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1159.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,521.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,985.32,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC CANN 2.7 X 160,21794,CDM,0272,RC,,,,,,outpatient,facility,,,1159.2,1159.2,129.72,1159.2,,753.48,,,percent of total billed charges,,,,,,,,,,,,,,,985.32,,,percent of total billed charges,,,,,,347.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,544.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,220.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,220.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,869.4,,,percent of total billed charges,,,,,,811.44,,,percent of total billed charges,,,,,,811.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,753.48,,,percent of total billed charges,,,,,,278.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",782.46,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1159.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,486.86,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",811.44,,,percent of total billed charges,,,,,,,,,,,,,,,1159.2,,,percent of total billed charges,,,,,,808.54,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,823.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,811.44,,,percent of total billed charges,,,,,,695.52,,,percent of total billed charges,,,,,,521.64,,,percent of total billed charges,,,,,,,,,,,,,,,985.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1159.2,,,percent of total billed charges,,,,,,1159.2,,,percent of total billed charges,,,,,,498.46,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1159.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1159.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,869.4,,,percent of total billed charges,,,,,,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1159.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1159.2,,,percent of total billed charges,,,,,,521.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,869.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1159.2,,,fee schedule,,,,,,1159.2,,,percent of total billed charges,,,,,,1159.2,,,percent of total billed charges,,,,,,1159.2,,,percent of total billed charges,,,,,,556.42,,,percent of total billed charges,,,,,,,,,,,,,,,683.93,,,percent of total billed charges,,,,,,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1159.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,985.32,,,percent of total billed charges,,,,,,869.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 36,21795,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 36,21795,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 48,21796,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 48,21796,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 50,21797,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 50,21797,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
RING DEP LOCK DURALOC DYNAMIC 56MM,21804,CDM,0278,RC,,,,,,inpatient,facility,,,731,731,328.95,731,,,,,,,,,,,,,,,,,,,,621.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,584.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,548.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.05,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,441.89,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",519.01,,,percent of total billed charges,,,,,,,,,,,,,,,402.05,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,511.7,,,percent of total billed charges,,,,,,438.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,621.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.05,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,402.05,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731,,,percent of total billed charges,,,,,,402.05,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,548.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,731,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,328.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.05,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,621.35,,,percent of total billed charges,,,,,,475.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
RING DEP LOCK DURALOC DYNAMIC 56MM,21804,CDM,0278,RC,,,,,,outpatient,facility,,,731,731,129.72,731,,475.15,,,percent of total billed charges,,,,,,,,,,,,,,,621.35,,,percent of total billed charges,,,,,,219.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,343.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,138.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,138.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,402.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,402.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,402.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,548.25,,,percent of total billed charges,,,,,,511.7,,,percent of total billed charges,,,,,,511.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,475.15,,,percent of total billed charges,,,,,,402.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,731,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,307.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",511.7,,,percent of total billed charges,,,,,,402.05,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,731,,,percent of total billed charges,,,,,,509.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,519.01,,,percent of total billed charges,,,,,,,,,,,,,,,402.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,511.7,,,percent of total billed charges,,,,,,438.6,,,percent of total billed charges,,,,,,328.95,,,percent of total billed charges,,,,,,,,,,,,,,,621.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,402.05,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,731,,,percent of total billed charges,,,,,,731,,,percent of total billed charges,,,,,,402.05,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,731,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,731,,,percent of total billed charges,,,,,,402.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,548.25,,,percent of total billed charges,,,,,,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,731,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,731,,,percent of total billed charges,,,,,,328.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,548.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,402.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,731,,,fee schedule,,,,,,731,,,percent of total billed charges,,,,,,731,,,percent of total billed charges,,,,,,731,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,731,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,621.35,,,percent of total billed charges,,,,,,548.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GUIDE PIN BIO VHS TH 1 8 X 9,21806,CDM,0272,RC,,,,,,inpatient,facility,,,367.5,367.5,165.38,367.5,,,,,,,,,,,,,,,,,,,,312.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.25,,,percent of total billed charges,,,,,,220.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,312.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,367.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,165.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.38,,,percent of total billed charges,,,,,,,,,,,,,,
GUIDE PIN BIO VHS TH 1 8 X 9,21806,CDM,0272,RC,,,,,,outpatient,facility,,,367.5,367.5,69.83,1016,,238.88,,,percent of total billed charges,,,,,,,,,,,,,,,312.38,,,percent of total billed charges,,,,,,110.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,275.62,,,percent of total billed charges,,,,,,257.25,,,percent of total billed charges,,,,,,257.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,238.88,,,percent of total billed charges,,,,,,88.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.06,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,367.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,154.35,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",257.25,,,percent of total billed charges,,,,,,,,,,,,,,,367.5,,,percent of total billed charges,,,,,,256.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,260.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.25,,,percent of total billed charges,,,,,,220.5,,,percent of total billed charges,,,,,,165.38,,,percent of total billed charges,,,,,,,,,,,,,,,312.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.5,,,percent of total billed charges,,,,,,367.5,,,percent of total billed charges,,,,,,158.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,367.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,367.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.62,,,percent of total billed charges,,,,,,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,367.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,367.5,,,percent of total billed charges,,,,,,165.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,367.5,,,fee schedule,,,,,,367.5,,,percent of total billed charges,,,,,,367.5,,,percent of total billed charges,,,,,,367.5,,,percent of total billed charges,,,,,,176.4,,,percent of total billed charges,,,,,,,,,,,,,,,216.82,,,percent of total billed charges,,,,,,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,367.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,312.38,,,percent of total billed charges,,,,,,275.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DISTRACTION BLUNT DISP 14MM  i,2181,CDM,0272,RC,,,,,,inpatient,facility,,,157.5,157.5,70.88,157.5,,,,,,,,,,,,,,,,,,,,133.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,110.25,,,percent of total billed charges,,,,,,94.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,133.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.88,,,percent of total billed charges,,,,,,,,,,,,,,
SCR DISTRACTION BLUNT DISP 14MM  i,2181,CDM,0272,RC,,,,,,outpatient,facility,,,157.5,157.5,29.93,1016,,102.38,,,percent of total billed charges,,,,,,,,,,,,,,,133.88,,,percent of total billed charges,,,,,,47.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,74.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,118.12,,,percent of total billed charges,,,,,,110.25,,,percent of total billed charges,,,,,,110.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,102.38,,,percent of total billed charges,,,,,,37.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",106.31,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,157.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,66.15,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",110.25,,,percent of total billed charges,,,,,,,,,,,,,,,157.5,,,percent of total billed charges,,,,,,109.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,111.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,110.25,,,percent of total billed charges,,,,,,94.5,,,percent of total billed charges,,,,,,70.88,,,percent of total billed charges,,,,,,,,,,,,,,,133.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.5,,,percent of total billed charges,,,,,,157.5,,,percent of total billed charges,,,,,,67.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,157.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.12,,,percent of total billed charges,,,,,,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,157.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,157.5,,,percent of total billed charges,,,,,,70.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.5,,,fee schedule,,,,,,157.5,,,percent of total billed charges,,,,,,157.5,,,percent of total billed charges,,,,,,157.5,,,percent of total billed charges,,,,,,75.6,,,percent of total billed charges,,,,,,,,,,,,,,,92.92,,,percent of total billed charges,,,,,,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,157.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.88,,,percent of total billed charges,,,,,,118.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DRAIN FLEXIMA APD LOOP FIRM 10FR 25CM  i,21845,CDM,0272,RC,,,,,,inpatient,facility,,,276.5,276.5,124.42,276.5,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DRAIN FLEXIMA APD LOOP FIRM 10FR 25CM  i,21845,CDM,0272,RC,,,,,,outpatient,facility,,,276.5,276.5,52.54,1016,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,82.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,129.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,207.38,,,percent of total billed charges,,,,,,193.55,,,percent of total billed charges,,,,,,193.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,66.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",186.64,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.13,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",193.55,,,percent of total billed charges,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,192.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,196.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,193.55,,,percent of total billed charges,,,,,,165.9,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,235.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,118.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,276.5,,,percent of total billed charges,,,,,,124.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.5,,,fee schedule,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,276.5,,,percent of total billed charges,,,,,,132.72,,,percent of total billed charges,,,,,,,,,,,,,,,163.13,,,percent of total billed charges,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,276.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,235.02,,,percent of total billed charges,,,,,,207.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE GLIDE W ANGL .035 X 260  i,21872,CDM,0272,RC,,,,,,inpatient,facility,,,176.05,176.05,79.22,176.05,,,,,,,,,,,,,,,,,,,,149.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,123.24,,,percent of total billed charges,,,,,,105.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,149.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,176.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.64,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE GLIDE W ANGL .035 X 260  i,21872,CDM,0272,RC,,,,,,outpatient,facility,,,176.05,176.05,33.45,1016,,114.43,,,percent of total billed charges,,,,,,,,,,,,,,,149.64,,,percent of total billed charges,,,,,,52.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,82.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,33.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,132.03,,,percent of total billed charges,,,,,,123.23,,,percent of total billed charges,,,,,,123.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,114.43,,,percent of total billed charges,,,,,,42.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.83,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,176.05,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,73.94,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",123.23,,,percent of total billed charges,,,,,,,,,,,,,,,176.05,,,percent of total billed charges,,,,,,122.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,123.24,,,percent of total billed charges,,,,,,105.63,,,percent of total billed charges,,,,,,79.22,,,percent of total billed charges,,,,,,,,,,,,,,,149.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.05,,,percent of total billed charges,,,,,,176.05,,,percent of total billed charges,,,,,,75.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,176.05,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,176.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.04,,,percent of total billed charges,,,,,,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,176.05,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,176.05,,,percent of total billed charges,,,,,,79.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.05,,,fee schedule,,,,,,176.05,,,percent of total billed charges,,,,,,176.05,,,percent of total billed charges,,,,,,176.05,,,percent of total billed charges,,,,,,84.5,,,percent of total billed charges,,,,,,,,,,,,,,,103.87,,,percent of total billed charges,,,,,,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,176.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,149.64,,,percent of total billed charges,,,,,,132.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ADHESIVE MEDICAL MEDTRONIC,21904,CDM,0272,RC,,,,,,inpatient,facility,,,84,84,37.8,84,,,,,,,,,,,,,,,,,,,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.8,,,percent of total billed charges,,,,,,50.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,37.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,
ADHESIVE MEDICAL MEDTRONIC,21904,CDM,0272,RC,,,,,,outpatient,facility,,,84,84,15.96,1016,,54.6,,,percent of total billed charges,,,,,,,,,,,,,,,71.4,,,percent of total billed charges,,,,,,25.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,39.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,15.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,63,,,percent of total billed charges,,,,,,58.8,,,percent of total billed charges,,,,,,58.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,54.6,,,percent of total billed charges,,,,,,20.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",56.7,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,84,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,35.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",58.8,,,percent of total billed charges,,,,,,,,,,,,,,,84,,,percent of total billed charges,,,,,,58.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,59.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.8,,,percent of total billed charges,,,,,,50.4,,,percent of total billed charges,,,,,,37.8,,,percent of total billed charges,,,,,,,,,,,,,,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,percent of total billed charges,,,,,,84,,,percent of total billed charges,,,,,,36.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63,,,percent of total billed charges,,,,,,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,84,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,84,,,percent of total billed charges,,,,,,37.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84,,,fee schedule,,,,,,84,,,percent of total billed charges,,,,,,84,,,percent of total billed charges,,,,,,84,,,percent of total billed charges,,,,,,40.32,,,percent of total billed charges,,,,,,,,,,,,,,,49.56,,,percent of total billed charges,,,,,,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,71.4,,,percent of total billed charges,,,,,,63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ENDOTRACH N CUFF 4.5MM,21907,CDM,0272,RC,,,,,,inpatient,facility,,,4.53,4.53,2.04,4.53,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ENDOTRACH N CUFF 4.5MM,21907,CDM,0272,RC,,,,,,outpatient,facility,,,4.53,4.53,0.86,1016,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.4,,,percent of total billed charges,,,,,,3.17,,,percent of total billed charges,,,,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,1.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.06,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,3.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,1.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,fee schedule,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.85,,,percent of total billed charges,,,,,,3.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE ZIM PLAIN 2.4 X 100,21914,CDM,0272,RC,,,,,,inpatient,facility,,,76.3,76.3,34.34,76.3,,,,,,,,,,,,,,,,,,,,64.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,53.41,,,percent of total billed charges,,,,,,45.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,64.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,34.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.85,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE ZIM PLAIN 2.4 X 100,21914,CDM,0272,RC,,,,,,outpatient,facility,,,76.3,76.3,14.5,1016,,49.59,,,percent of total billed charges,,,,,,,,,,,,,,,64.85,,,percent of total billed charges,,,,,,22.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,57.22,,,percent of total billed charges,,,,,,53.41,,,percent of total billed charges,,,,,,53.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,18.31,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",51.5,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,76.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,32.05,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",53.41,,,percent of total billed charges,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,53.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,54.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,53.41,,,percent of total billed charges,,,,,,45.78,,,percent of total billed charges,,,,,,34.34,,,percent of total billed charges,,,,,,,,,,,,,,,64.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,76.3,,,percent of total billed charges,,,,,,32.81,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,76.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,76.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.22,,,percent of total billed charges,,,,,,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,76.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.3,,,percent of total billed charges,,,,,,34.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.3,,,fee schedule,,,,,,76.3,,,percent of total billed charges,,,,,,76.3,,,percent of total billed charges,,,,,,76.3,,,percent of total billed charges,,,,,,36.62,,,percent of total billed charges,,,,,,,,,,,,,,,45.02,,,percent of total billed charges,,,,,,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,76.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,64.85,,,percent of total billed charges,,,,,,57.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE ENDOTRACH N CUFF SHILEY 3.0MM,21979,CDM,0272,RC,,,,,,inpatient,facility,,,4.53,4.53,2.04,4.53,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE ENDOTRACH N CUFF SHILEY 3.0MM,21979,CDM,0272,RC,,,,,,outpatient,facility,,,4.53,4.53,0.86,1016,,2.94,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,1.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.4,,,percent of total billed charges,,,,,,3.17,,,percent of total billed charges,,,,,,3.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.94,,,percent of total billed charges,,,,,,1.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.06,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.17,,,percent of total billed charges,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,3.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.17,,,percent of total billed charges,,,,,,2.72,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,3.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,1.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.53,,,percent of total billed charges,,,,,,2.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.53,,,fee schedule,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,4.53,,,percent of total billed charges,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,2.67,,,percent of total billed charges,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.85,,,percent of total billed charges,,,,,,3.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T HUM LOCK SS 4.0 X 54,22115,CDM,0278,RC,,,,,,inpatient,facility,,,171.3,171.3,77.09,171.3,,,,,,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,128.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.55,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",121.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119.91,,,percent of total billed charges,,,,,,102.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,77.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,111.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T HUM LOCK SS 4.0 X 54,22115,CDM,0278,RC,,,,,,outpatient,facility,,,171.3,171.3,32.55,171.3,,111.34,,,percent of total billed charges,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,51.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,80.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,94.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,94.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,128.48,,,percent of total billed charges,,,,,,119.91,,,percent of total billed charges,,,,,,119.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,111.35,,,percent of total billed charges,,,,,,41.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,171.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,71.95,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",119.91,,,percent of total billed charges,,,,,,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,119.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,121.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119.91,,,percent of total billed charges,,,,,,102.78,,,percent of total billed charges,,,,,,77.09,,,percent of total billed charges,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,171.3,,,percent of total billed charges,,,,,,73.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,171.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.48,,,percent of total billed charges,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,171.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.3,,,percent of total billed charges,,,,,,77.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,,fee schedule,,,,,,171.3,,,percent of total billed charges,,,,,,171.3,,,percent of total billed charges,,,,,,171.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.61,,,percent of total billed charges,,,,,,128.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T HUM LOCK SS 4.0 X 26,22120,CDM,0278,RC,,,,,,inpatient,facility,,,171.3,171.3,77.09,171.3,,,,,,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,128.48,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.55,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",121.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119.91,,,percent of total billed charges,,,,,,102.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,77.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,111.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T HUM LOCK SS 4.0 X 26,22120,CDM,0278,RC,,,,,,outpatient,facility,,,171.3,171.3,32.55,171.3,,111.34,,,percent of total billed charges,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,51.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,80.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,94.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,94.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,128.48,,,percent of total billed charges,,,,,,119.91,,,percent of total billed charges,,,,,,119.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,111.35,,,percent of total billed charges,,,,,,41.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,171.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,71.95,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",119.91,,,percent of total billed charges,,,,,,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,119.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,121.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119.91,,,percent of total billed charges,,,,,,102.78,,,percent of total billed charges,,,,,,77.09,,,percent of total billed charges,,,,,,,,,,,,,,,145.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,171.3,,,percent of total billed charges,,,,,,73.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,171.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.48,,,percent of total billed charges,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,171.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.3,,,percent of total billed charges,,,,,,77.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,,fee schedule,,,,,,171.3,,,percent of total billed charges,,,,,,171.3,,,percent of total billed charges,,,,,,171.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,171.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.61,,,percent of total billed charges,,,,,,128.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHUNT ARGYLE CAROTID STRL MULTIPK  i,22270,CDM,0272,RC,,,,,,inpatient,facility,,,95.72,95.72,43.07,95.72,,,,,,,,,,,,,,,,,,,,81.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,67,,,percent of total billed charges,,,,,,57.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,81.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,95.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,43.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.36,,,percent of total billed charges,,,,,,,,,,,,,,
SHUNT ARGYLE CAROTID STRL MULTIPK  i,22270,CDM,0272,RC,,,,,,outpatient,facility,,,95.72,95.72,18.19,1016,,62.22,,,percent of total billed charges,,,,,,,,,,,,,,,81.36,,,percent of total billed charges,,,,,,28.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,44.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,18.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,71.79,,,percent of total billed charges,,,,,,67,,,percent of total billed charges,,,,,,67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,62.22,,,percent of total billed charges,,,,,,22.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",64.61,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,95.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,40.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",67,,,percent of total billed charges,,,,,,,,,,,,,,,95.72,,,percent of total billed charges,,,,,,66.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,67.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,67,,,percent of total billed charges,,,,,,57.43,,,percent of total billed charges,,,,,,43.07,,,percent of total billed charges,,,,,,,,,,,,,,,81.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.72,,,percent of total billed charges,,,,,,95.72,,,percent of total billed charges,,,,,,41.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,95.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,95.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.79,,,percent of total billed charges,,,,,,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,95.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,95.72,,,percent of total billed charges,,,,,,43.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.72,,,fee schedule,,,,,,95.72,,,percent of total billed charges,,,,,,95.72,,,percent of total billed charges,,,,,,95.72,,,percent of total billed charges,,,,,,45.95,,,percent of total billed charges,,,,,,,,,,,,,,,56.47,,,percent of total billed charges,,,,,,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,95.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.36,,,percent of total billed charges,,,,,,71.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR BIO DFS CORT TAPER TH 3.3 3.0 X 70 X 20,22394,CDM,0278,RC,,,,,,inpatient,facility,,,250,250,112.5,250,,,,,,,,,,,,,,,,,,,,212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,187.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",177.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,175,,,percent of total billed charges,,,,,,150,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,250,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,112.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.5,,,percent of total billed charges,,,,,,162.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR BIO DFS CORT TAPER TH 3.3 3.0 X 70 X 20,22394,CDM,0278,RC,,,,,,outpatient,facility,,,250,250,47.5,250,,162.5,,,percent of total billed charges,,,,,,,,,,,,,,,212.5,,,percent of total billed charges,,,,,,75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,117.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,47.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,47.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,137.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,137.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,137.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,187.5,,,percent of total billed charges,,,,,,175,,,percent of total billed charges,,,,,,175,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,162.5,,,percent of total billed charges,,,,,,60,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,250,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,105,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",175,,,percent of total billed charges,,,,,,,,,,,,,,,250,,,percent of total billed charges,,,,,,174.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,177.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,175,,,percent of total billed charges,,,,,,150,,,percent of total billed charges,,,,,,112.5,,,percent of total billed charges,,,,,,,,,,,,,,,212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250,,,percent of total billed charges,,,,,,250,,,percent of total billed charges,,,,,,107.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,250,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,250,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.5,,,percent of total billed charges,,,,,,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,250,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,250,,,percent of total billed charges,,,,,,112.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250,,,fee schedule,,,,,,250,,,percent of total billed charges,,,,,,250,,,percent of total billed charges,,,,,,250,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,250,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,212.5,,,percent of total billed charges,,,,,,187.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT BIO DFS 2.7MM COMPLETE,22396,CDM,0272,RC,,,,,,inpatient,facility,,,678.65,678.65,305.39,678.65,,,,,,,,,,,,,,,,,,,,576.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,475.06,,,percent of total billed charges,,,,,,407.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,576.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,678.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,678.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,305.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,576.85,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT BIO DFS 2.7MM COMPLETE,22396,CDM,0272,RC,,,,,,outpatient,facility,,,678.65,678.65,128.94,1016,,441.12,,,percent of total billed charges,,,,,,,,,,,,,,,576.85,,,percent of total billed charges,,,,,,203.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,318.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,128.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,128.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,508.99,,,percent of total billed charges,,,,,,475.06,,,percent of total billed charges,,,,,,475.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,441.12,,,percent of total billed charges,,,,,,162.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",458.09,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,678.65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,285.03,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",475.05,,,percent of total billed charges,,,,,,,,,,,,,,,678.65,,,percent of total billed charges,,,,,,473.36,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,481.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,475.06,,,percent of total billed charges,,,,,,407.19,,,percent of total billed charges,,,,,,305.39,,,percent of total billed charges,,,,,,,,,,,,,,,576.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,678.65,,,percent of total billed charges,,,,,,678.65,,,percent of total billed charges,,,,,,291.82,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,678.65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,678.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.99,,,percent of total billed charges,,,,,,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,678.65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,678.65,,,percent of total billed charges,,,,,,305.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,678.65,,,fee schedule,,,,,,678.65,,,percent of total billed charges,,,,,,678.65,,,percent of total billed charges,,,,,,678.65,,,percent of total billed charges,,,,,,325.75,,,percent of total billed charges,,,,,,,,,,,,,,,400.4,,,percent of total billed charges,,,,,,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,678.65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,576.85,,,percent of total billed charges,,,,,,508.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR KNEE SCORPIO PS WAFFLE LFIT LT 7 NC,22422,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR KNEE SCORPIO PS WAFFLE LFIT LT 7 NC,22422,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD ZIM HIP FEM COCR 12 14 28   0 NC,22427,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD ZIM HIP FEM COCR 12 14 28   0 NC,22427,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC CANN 2.0 X 150,22461,CDM,0272,RC,,,,,,inpatient,facility,,,1081.08,1081.08,486.49,1081.08,,,,,,,,,,,,,,,,,,,,918.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,810.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,702.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,767.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,756.76,,,percent of total billed charges,,,,,,648.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,918.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1081.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,810.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1081.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,486.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,918.92,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC CANN 2.0 X 150,22461,CDM,0272,RC,,,,,,outpatient,facility,,,1081.08,1081.08,129.72,1081.08,,702.7,,,percent of total billed charges,,,,,,,,,,,,,,,918.92,,,percent of total billed charges,,,,,,324.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,508.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,205.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,205.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,810.81,,,percent of total billed charges,,,,,,756.76,,,percent of total billed charges,,,,,,756.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,702.7,,,percent of total billed charges,,,,,,259.46,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",729.73,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1081.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,454.05,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",756.76,,,percent of total billed charges,,,,,,,,,,,,,,,1081.08,,,percent of total billed charges,,,,,,754.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,767.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,756.76,,,percent of total billed charges,,,,,,648.65,,,percent of total billed charges,,,,,,486.49,,,percent of total billed charges,,,,,,,,,,,,,,,918.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1081.08,,,percent of total billed charges,,,,,,1081.08,,,percent of total billed charges,,,,,,464.86,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1081.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1081.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,810.81,,,percent of total billed charges,,,,,,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1081.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1081.08,,,percent of total billed charges,,,,,,486.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,810.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1081.08,,,fee schedule,,,,,,1081.08,,,percent of total billed charges,,,,,,1081.08,,,percent of total billed charges,,,,,,1081.08,,,percent of total billed charges,,,,,,518.92,,,percent of total billed charges,,,,,,,,,,,,,,,637.84,,,percent of total billed charges,,,,,,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1081.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,918.92,,,percent of total billed charges,,,,,,810.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE PT GRAPHIX STRT .014 X 2 X 182  c,22676,CDM,0272,RC,,,,,,inpatient,facility,,,280,280,126,280,,,,,,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,196,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,280,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE PT GRAPHIX STRT .014 X 2 X 182  c,22676,CDM,0272,RC,,,,,,outpatient,facility,,,280,280,53.2,1016,,182,,,percent of total billed charges,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,131.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,53.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,53.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,210,,,percent of total billed charges,,,,,,196,,,percent of total billed charges,,,,,,196,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,182,,,percent of total billed charges,,,,,,67.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",189,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,280,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,117.6,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",196,,,percent of total billed charges,,,,,,,,,,,,,,,280,,,percent of total billed charges,,,,,,195.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,198.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,196,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,percent of total billed charges,,,,,,280,,,percent of total billed charges,,,,,,120.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,280,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210,,,percent of total billed charges,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,280,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,280,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,fee schedule,,,,,,280,,,percent of total billed charges,,,,,,280,,,percent of total billed charges,,,,,,280,,,percent of total billed charges,,,,,,134.4,,,percent of total billed charges,,,,,,,,,,,,,,,165.2,,,percent of total billed charges,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,238,,,percent of total billed charges,,,,,,210,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR STR XIA III MA TI 5.0 X 40,22690,CDM,0278,RC,,,,,,inpatient,facility,,,1200,1200,540,1200,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1020,,,percent of total billed charges,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,960,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,900,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,660,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,725.4,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",852,,,percent of total billed charges,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,840,,,percent of total billed charges,,,,,,720,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1020,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1200,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,900,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1200,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,540,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1020,,,percent of total billed charges,,,,,,780,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR STR XIA III MA TI 5.0 X 40,22690,CDM,0278,RC,,,,,,outpatient,facility,,,1200,1200,129.72,1200,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1020,,,percent of total billed charges,,,,,,360,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,228,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,228,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,900,,,percent of total billed charges,,,,,,840,,,percent of total billed charges,,,,,,840,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,780,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1200,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,840,,,percent of total billed charges,,,,,,660,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1200,,,percent of total billed charges,,,,,,837,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,852,,,percent of total billed charges,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,840,,,percent of total billed charges,,,,,,720,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1020,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,660,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1200,,,percent of total billed charges,,,,,,1200,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1200,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1200,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,900,,,percent of total billed charges,,,,,,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1200,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1200,,,percent of total billed charges,,,,,,540,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,900,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1200,,,fee schedule,,,,,,1200,,,percent of total billed charges,,,,,,1200,,,percent of total billed charges,,,,,,1200,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,660,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1200,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1020,,,percent of total billed charges,,,,,,900,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 26 X 10 X 52,22711,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 26 X 10 X 52,22711,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEM DEP KNEE PFC SIGMA SUB RT SZ4,22732,CDM,0278,RC,,,,,,inpatient,facility,,,3360,3360,1512,3360,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2856,,,percent of total billed charges,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2688,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2520,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1848,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2031.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2385.6,,,percent of total billed charges,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2352,,,percent of total billed charges,,,,,,2016,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2856,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3360,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2520,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1512,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2856,,,percent of total billed charges,,,,,,2184,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEM DEP KNEE PFC SIGMA SUB RT SZ4,22732,CDM,0278,RC,,,,,,outpatient,facility,,,3360,3360,129.72,3360,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2856,,,percent of total billed charges,,,,,,1008,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,638.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,638.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2520,,,percent of total billed charges,,,,,,2352,,,percent of total billed charges,,,,,,2352,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2184,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2352,,,percent of total billed charges,,,,,,1848,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,,percent of total billed charges,,,,,,2343.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2385.6,,,percent of total billed charges,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2352,,,percent of total billed charges,,,,,,2016,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2856,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2520,,,percent of total billed charges,,,,,,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3360,,,percent of total billed charges,,,,,,1512,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2520,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3360,,,fee schedule,,,,,,3360,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2856,,,percent of total billed charges,,,,,,2520,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEM DEP KNEE PFC SIGMA SUB LT SZ3,22733,CDM,0278,RC,,,,,,inpatient,facility,,,3360,3360,1512,3360,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2856,,,percent of total billed charges,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2688,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2520,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1848,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2031.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2385.6,,,percent of total billed charges,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2352,,,percent of total billed charges,,,,,,2016,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2856,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3360,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2520,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1512,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2856,,,percent of total billed charges,,,,,,2184,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEM DEP KNEE PFC SIGMA SUB LT SZ3,22733,CDM,0278,RC,,,,,,outpatient,facility,,,3360,3360,129.72,3360,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2856,,,percent of total billed charges,,,,,,1008,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,638.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,638.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2520,,,percent of total billed charges,,,,,,2352,,,percent of total billed charges,,,,,,2352,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2184,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2352,,,percent of total billed charges,,,,,,1848,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,,percent of total billed charges,,,,,,2343.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2385.6,,,percent of total billed charges,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2352,,,percent of total billed charges,,,,,,2016,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2856,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1848,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2520,,,percent of total billed charges,,,,,,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3360,,,percent of total billed charges,,,,,,1512,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2520,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3360,,,fee schedule,,,,,,3360,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1848,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2856,,,percent of total billed charges,,,,,,2520,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP DHS SS 95DG 14H 25 X 242,22741,CDM,0278,RC,,,,,,inpatient,facility,,,2506,2506,1127.7,2506,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2130.1,,,percent of total billed charges,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2004.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1879.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1378.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1514.88,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1779.26,,,percent of total billed charges,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1754.2,,,percent of total billed charges,,,,,,1503.6,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2130.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2506,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2506,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1127.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.1,,,percent of total billed charges,,,,,,1628.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP DHS SS 95DG 14H 25 X 242,22741,CDM,0278,RC,,,,,,outpatient,facility,,,2506,2506,129.72,2506,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2130.1,,,percent of total billed charges,,,,,,751.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,476.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,476.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1879.5,,,percent of total billed charges,,,,,,1754.2,,,percent of total billed charges,,,,,,1754.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1628.9,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2506,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1754.2,,,percent of total billed charges,,,,,,1378.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,,percent of total billed charges,,,,,,1747.94,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1779.26,,,percent of total billed charges,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1754.2,,,percent of total billed charges,,,,,,1503.6,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2130.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,,percent of total billed charges,,,,,,2506,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2506,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,,,,,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2506,,,percent of total billed charges,,,,,,1127.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2506,,,fee schedule,,,,,,2506,,,percent of total billed charges,,,,,,2506,,,percent of total billed charges,,,,,,2506,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2130.1,,,percent of total billed charges,,,,,,1879.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
MESH PERFIX PLUG LRG 1.6 X 1.9  i,22744,CDM,0278,RC,,,,,,inpatient,facility,,,278.2,278.2,125.19,278.2,,,,,,,,,,,,,,,,,,,,236.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,208.65,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.17,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",197.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,194.74,,,percent of total billed charges,,,,,,166.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,236.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,125.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.47,,,percent of total billed charges,,,,,,180.83,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
MESH PERFIX PLUG LRG 1.6 X 1.9  i,22744,CDM,0278,RC,,,,,,outpatient,facility,,,278.2,278.2,52.86,278.2,,180.83,,,percent of total billed charges,,,,,,,,,,,,,,,236.47,,,percent of total billed charges,,,,,,83.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,130.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,52.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,153.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,153.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,153.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,208.64,,,percent of total billed charges,,,,,,194.74,,,percent of total billed charges,,,,,,194.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,180.83,,,percent of total billed charges,,,,,,66.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,278.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",194.74,,,percent of total billed charges,,,,,,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,194.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,197.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,194.74,,,percent of total billed charges,,,,,,166.92,,,percent of total billed charges,,,,,,125.19,,,percent of total billed charges,,,,,,,,,,,,,,,236.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,278.2,,,percent of total billed charges,,,,,,119.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,278.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,278.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.65,,,percent of total billed charges,,,,,,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,278.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,278.2,,,percent of total billed charges,,,,,,125.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.2,,,fee schedule,,,,,,278.2,,,percent of total billed charges,,,,,,278.2,,,percent of total billed charges,,,,,,278.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,278.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,236.47,,,percent of total billed charges,,,,,,208.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IVUS ATLANTIS SR MHZ 40  c,22837,CDM,0272,RC,,,,,,inpatient,facility,,,1995,1995,897.75,1995,,,,,,,,,,,,,,,,,,,,1695.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1496.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1416.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1396.5,,,percent of total billed charges,,,,,,1197,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1695.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1995,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1496.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1995,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,897.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1695.75,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IVUS ATLANTIS SR MHZ 40  c,22837,CDM,0272,RC,,,,,,outpatient,facility,,,1995,1995,129.72,1995,,1296.75,,,percent of total billed charges,,,,,,,,,,,,,,,1695.75,,,percent of total billed charges,,,,,,598.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,937.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,379.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,379.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1496.26,,,percent of total billed charges,,,,,,1396.5,,,percent of total billed charges,,,,,,1396.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1296.75,,,percent of total billed charges,,,,,,478.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1346.62,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1995,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,837.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1396.5,,,percent of total billed charges,,,,,,,,,,,,,,,1995,,,percent of total billed charges,,,,,,1391.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1416.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1396.5,,,percent of total billed charges,,,,,,1197,,,percent of total billed charges,,,,,,897.75,,,percent of total billed charges,,,,,,,,,,,,,,,1695.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1995,,,percent of total billed charges,,,,,,1995,,,percent of total billed charges,,,,,,857.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1995,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1995,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1496.25,,,percent of total billed charges,,,,,,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1995,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1995,,,percent of total billed charges,,,,,,897.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1496.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1995,,,fee schedule,,,,,,1995,,,percent of total billed charges,,,,,,1995,,,percent of total billed charges,,,,,,1995,,,percent of total billed charges,,,,,,957.6,,,percent of total billed charges,,,,,,,,,,,,,,,1177.05,,,percent of total billed charges,,,,,,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1995,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1695.75,,,percent of total billed charges,,,,,,1496.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI AL3 5FR 100CM  ORDER SETS OF 5,22840,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI AL3 5FR 100CM  ORDER SETS OF 5,22840,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI RCB 5FR 100CM  ORDER SETS OF 5,22841,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI RCB 5FR 100CM  ORDER SETS OF 5,22841,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI AL1 5FR 100CM  ORDER SETS OF 5,22842,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI AL1 5FR 100CM  ORDER SETS OF 5,22842,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI AL2 5FR 100CM  ORDER SETS OF 5,22843,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI AL2 5FR 100CM  ORDER SETS OF 5,22843,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI AR1 MOD 5FR 100CM  ORDER SETS OF,22844,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI AR1 MOD 5FR 100CM  ORDER SETS OF,22844,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI AR2 MOD 5FR 100CM  ORDER SETS OF,22845,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI AR2 MOD 5FR 100CM  ORDER SETS OF,22845,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JL6 5FR 100CM  ORDER SETS OF 5,22846,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JL6 5FR 100CM  ORDER SETS OF 5,22846,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI PIG 145DG 6SH 5FR 110CM  ORDER SE,22847,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI PIG 145DG 6SH 5FR 110CM  ORDER SE,22847,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JL3.5 5FR 100CM  ORDER SETS OF 5,22849,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JL3.5 5FR 100CM  ORDER SETS OF 5,22849,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JR5 5FR 100CM  ORDER SETS OF 5,22850,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JR5 5FR 100CM  ORDER SETS OF 5,22850,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JR3.5 5FR 100CM  ORDER SETS OF 5,22851,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JR3.5 5FR 100CM  ORDER SETS OF 5,22851,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI LCB 5FR 100CM  ORDER SETS OF 5,22852,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI LCB 5FR 100CM  ORDER SETS OF 5,22852,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE HT IRONMAN STRT .014 X 3 X 300  c,22853,CDM,0272,RC,,,,,,inpatient,facility,,,262.5,262.5,118.13,262.5,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.75,,,percent of total billed charges,,,,,,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,118.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE HT IRONMAN STRT .014 X 3 X 300  c,22853,CDM,0272,RC,,,,,,outpatient,facility,,,262.5,262.5,49.88,1016,,170.63,,,percent of total billed charges,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,78.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,123.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,49.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,196.88,,,percent of total billed charges,,,,,,183.75,,,percent of total billed charges,,,,,,183.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,170.63,,,percent of total billed charges,,,,,,63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",177.19,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,262.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",183.75,,,percent of total billed charges,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,183.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,186.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.75,,,percent of total billed charges,,,,,,157.5,,,percent of total billed charges,,,,,,118.13,,,percent of total billed charges,,,,,,,,,,,,,,,223.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,262.5,,,percent of total billed charges,,,,,,112.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,262.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,262.5,,,percent of total billed charges,,,,,,118.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,fee schedule,,,,,,262.5,,,percent of total billed charges,,,,,,262.5,,,percent of total billed charges,,,,,,262.5,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,154.88,,,percent of total billed charges,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,262.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,223.12,,,percent of total billed charges,,,,,,196.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHEATH EPS DAIG 6F  i,22870,CDM,0272,RC,,,,,,inpatient,facility,,,66.5,66.5,29.93,66.5,,,,,,,,,,,,,,,,,,,,56.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,46.55,,,percent of total billed charges,,,,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,56.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.52,,,percent of total billed charges,,,,,,,,,,,,,,
SHEATH EPS DAIG 6F  i,22870,CDM,0272,RC,,,,,,outpatient,facility,,,66.5,66.5,12.63,1016,,43.23,,,percent of total billed charges,,,,,,,,,,,,,,,56.52,,,percent of total billed charges,,,,,,19.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,12.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,49.88,,,percent of total billed charges,,,,,,46.55,,,percent of total billed charges,,,,,,46.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,43.23,,,percent of total billed charges,,,,,,15.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",44.89,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,66.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,27.93,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",46.55,,,percent of total billed charges,,,,,,,,,,,,,,,66.5,,,percent of total billed charges,,,,,,46.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,47.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,46.55,,,percent of total billed charges,,,,,,39.9,,,percent of total billed charges,,,,,,29.93,,,percent of total billed charges,,,,,,,,,,,,,,,56.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,,percent of total billed charges,,,,,,66.5,,,percent of total billed charges,,,,,,28.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.88,,,percent of total billed charges,,,,,,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,66.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,66.5,,,percent of total billed charges,,,,,,29.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.5,,,fee schedule,,,,,,66.5,,,percent of total billed charges,,,,,,66.5,,,percent of total billed charges,,,,,,66.5,,,percent of total billed charges,,,,,,31.92,,,percent of total billed charges,,,,,,,,,,,,,,,39.23,,,percent of total billed charges,,,,,,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,66.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.52,,,percent of total billed charges,,,,,,49.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX .45 20MEQ KCL 1000ML,22894,CDM,0258,RC,,,,,,inpatient,facility,,,7.08,7.08,3.19,7.08,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,4.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,
DEX .45 20MEQ KCL 1000ML,22894,CDM,0258,RC,,,,,,outpatient,facility,,,7.08,7.08,1.35,1016,,4.6,,,percent of total billed charges,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,2.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,5.31,,,percent of total billed charges,,,,,,4.96,,,percent of total billed charges,,,,,,4.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4.6,,,percent of total billed charges,,,,,,1.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,7.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.97,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.96,,,percent of total billed charges,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,,,,,4.94,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,4.25,,,percent of total billed charges,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,6.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,,,,,7.08,,,percent of total billed charges,,,,,,3.04,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.08,,,percent of total billed charges,,,,,,3.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.08,,,fee schedule,,,,,,7.08,,,percent of total billed charges,,,,,,7.08,,,percent of total billed charges,,,,,,7.08,,,percent of total billed charges,,,,,,3.4,,,percent of total billed charges,,,,,,,,,,,,,,,4.18,,,percent of total billed charges,,,,,,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.02,,,percent of total billed charges,,,,,,5.31,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
OSMITROL 20percent 500ML,22900,CDM,0258,RC,,,,,,inpatient,facility,,,35.94,35.94,16.17,35.94,,,,,,,,,,,,,,,,,,,,30.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.16,,,percent of total billed charges,,,,,,21.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,30.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,35.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.55,,,percent of total billed charges,,,,,,,,,,,,,,
OSMITROL 20percent 500ML,22900,CDM,0258,RC,,,,,,outpatient,facility,,,35.94,35.94,6.83,1016,,23.36,,,percent of total billed charges,,,,,,,,,,,,,,,30.55,,,percent of total billed charges,,,,,,10.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,26.96,,,percent of total billed charges,,,,,,25.16,,,percent of total billed charges,,,,,,25.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,,8.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,35.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,15.09,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",25.16,,,percent of total billed charges,,,,,,,,,,,,,,,35.94,,,percent of total billed charges,,,,,,25.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,25.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.16,,,percent of total billed charges,,,,,,21.56,,,percent of total billed charges,,,,,,16.17,,,percent of total billed charges,,,,,,,,,,,,,,,30.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.94,,,percent of total billed charges,,,,,,35.94,,,percent of total billed charges,,,,,,15.45,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,35.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,35.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.96,,,percent of total billed charges,,,,,,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,35.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,35.94,,,percent of total billed charges,,,,,,16.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.94,,,fee schedule,,,,,,35.94,,,percent of total billed charges,,,,,,35.94,,,percent of total billed charges,,,,,,35.94,,,percent of total billed charges,,,,,,17.25,,,percent of total billed charges,,,,,,,,,,,,,,,21.2,,,percent of total billed charges,,,,,,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,35.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,30.55,,,percent of total billed charges,,,,,,26.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX 5percent .9percent 20MEQ KCL 1000,22901,CDM,0258,RC,,,,,,inpatient,facility,,,9,9,4.05,9,,,,,,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,5.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent .9percent 20MEQ KCL 1000,22901,CDM,0258,RC,,,,,,outpatient,facility,,,9,9,1.71,1016,,5.85,,,percent of total billed charges,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,,,,2.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,6.75,,,percent of total billed charges,,,,,,6.3,,,percent of total billed charges,,,,,,6.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,5.85,,,percent of total billed charges,,,,,,2.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.78,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",6.3,,,percent of total billed charges,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,,,,6.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,6.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6.3,,,percent of total billed charges,,,,,,5.4,,,percent of total billed charges,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,,,,9,,,percent of total billed charges,,,,,,3.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,9,,,percent of total billed charges,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9,,,fee schedule,,,,,,9,,,percent of total billed charges,,,,,,9,,,percent of total billed charges,,,,,,9,,,percent of total billed charges,,,,,,4.32,,,percent of total billed charges,,,,,,,,,,,,,,,5.31,,,percent of total billed charges,,,,,,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.65,,,percent of total billed charges,,,,,,6.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
VALVE CRY AORTIC 25MM,22926,CDM,0278,RC,,,,,,inpatient,facility,,,24270,24270,10921.5,24270,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,20629.5,,,percent of total billed charges,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",13348.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19416,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,18202.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,13348.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14671.22,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",17231.7,,,percent of total billed charges,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,16989,,,percent of total billed charges,,,,,,14562,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,20629.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13348.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24270,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,18202.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,24270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,10921.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20629.5,,,percent of total billed charges,,,,,,15775.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
VALVE CRY AORTIC 25MM,22926,CDM,0278,RC,,,,,,outpatient,facility,,,24270,24270,129.72,24270,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,20629.5,,,percent of total billed charges,,,,,,7281,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",13348.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4611.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4611.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18202.5,,,percent of total billed charges,,,,,,16989,,,percent of total billed charges,,,,,,16989,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,15775.5,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,24270,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16989,,,percent of total billed charges,,,,,,13348.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,,percent of total billed charges,,,,,,16928.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,17231.7,,,percent of total billed charges,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16989,,,percent of total billed charges,,,,,,14562,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,20629.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13348.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,,percent of total billed charges,,,,,,24270,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24270,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,18202.5,,,percent of total billed charges,,,,,,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24270,,,percent of total billed charges,,,,,,10921.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18202.5,,,percent of total billed charges,,,,,,13348.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,24270,,,fee schedule,,,,,,24270,,,percent of total billed charges,,,,,,24270,,,percent of total billed charges,,,,,,24270,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,20629.5,,,percent of total billed charges,,,,,,18202.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 50MM NC,22930,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 50MM NC,22930,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEM DEP KNEE PFC SIGMA TC3 LT SZ3,22936,CDM,0278,RC,,,,,,inpatient,facility,,,12541,12541,5643.45,12541,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,10659.85,,,percent of total billed charges,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6897.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,6897.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10032.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,9405.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6897.55,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7581.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",8904.11,,,percent of total billed charges,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,8778.7,,,percent of total billed charges,,,,,,7524.6,,,percent of total billed charges,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,10659.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6897.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6897.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12541,,,percent of total billed charges,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,9405.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,12541,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5643.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6897.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10659.85,,,percent of total billed charges,,,,,,8151.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEM DEP KNEE PFC SIGMA TC3 LT SZ3,22936,CDM,0278,RC,,,,,,outpatient,facility,,,12541,12541,129.72,12541,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,10659.85,,,percent of total billed charges,,,,,,3762.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6897.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,6897.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2382.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2382.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9405.75,,,percent of total billed charges,,,,,,8778.7,,,percent of total billed charges,,,,,,8778.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8151.65,,,percent of total billed charges,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,12541,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8778.7,,,percent of total billed charges,,,,,,6897.55,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,12541,,,percent of total billed charges,,,,,,8747.35,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,8904.11,,,percent of total billed charges,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8778.7,,,percent of total billed charges,,,,,,7524.6,,,percent of total billed charges,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,10659.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6897.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6897.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,12541,,,percent of total billed charges,,,,,,12541,,,percent of total billed charges,,,,,,6897.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12541,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,12541,,,percent of total billed charges,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,9405.75,,,percent of total billed charges,,,,,,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,12541,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,12541,,,percent of total billed charges,,,,,,5643.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9405.75,,,percent of total billed charges,,,,,,6897.55,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,12541,,,fee schedule,,,,,,12541,,,percent of total billed charges,,,,,,12541,,,percent of total billed charges,,,,,,12541,,,percent of total billed charges,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6897.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,12541,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,10659.85,,,percent of total billed charges,,,,,,9405.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INSERT DEP TIBIA PFC TC3 3 X 20.0,22938,CDM,0278,RC,,,,,,inpatient,facility,,,4475,4475,2013.75,4475,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,3803.75,,,percent of total billed charges,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3580,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3356.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2461.25,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2705.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3177.25,,,percent of total billed charges,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3132.5,,,percent of total billed charges,,,,,,2685,,,percent of total billed charges,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.25,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4475,,,percent of total billed charges,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4475,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3803.75,,,percent of total billed charges,,,,,,2908.75,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
INSERT DEP TIBIA PFC TC3 3 X 20.0,22938,CDM,0278,RC,,,,,,outpatient,facility,,,4475,4475,129.72,4475,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3803.75,,,percent of total billed charges,,,,,,1342.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,850.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3356.26,,,percent of total billed charges,,,,,,3132.5,,,percent of total billed charges,,,,,,3132.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2908.75,,,percent of total billed charges,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4475,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3132.5,,,percent of total billed charges,,,,,,2461.25,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4475,,,percent of total billed charges,,,,,,3121.31,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3177.25,,,percent of total billed charges,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3132.5,,,percent of total billed charges,,,,,,2685,,,percent of total billed charges,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3803.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2461.25,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4475,,,percent of total billed charges,,,,,,4475,,,percent of total billed charges,,,,,,2461.25,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4475,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4475,,,percent of total billed charges,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3356.25,,,percent of total billed charges,,,,,,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4475,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4475,,,percent of total billed charges,,,,,,2013.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4475,,,fee schedule,,,,,,4475,,,percent of total billed charges,,,,,,4475,,,percent of total billed charges,,,,,,4475,,,percent of total billed charges,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2461.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4475,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3803.75,,,percent of total billed charges,,,,,,3356.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE MAILMAN STRT 300CM  c,22968,CDM,0272,RC,,,,,,inpatient,facility,,,280,280,126,280,,,,,,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,196,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,280,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE MAILMAN STRT 300CM  c,22968,CDM,0272,RC,,,,,,outpatient,facility,,,280,280,53.2,1016,,182,,,percent of total billed charges,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,131.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,53.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,53.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,210,,,percent of total billed charges,,,,,,196,,,percent of total billed charges,,,,,,196,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,182,,,percent of total billed charges,,,,,,67.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",189,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,280,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,117.6,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",196,,,percent of total billed charges,,,,,,,,,,,,,,,280,,,percent of total billed charges,,,,,,195.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,198.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,196,,,percent of total billed charges,,,,,,168,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,238,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,percent of total billed charges,,,,,,280,,,percent of total billed charges,,,,,,120.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,280,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210,,,percent of total billed charges,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,280,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,280,,,percent of total billed charges,,,,,,126,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280,,,fee schedule,,,,,,280,,,percent of total billed charges,,,,,,280,,,percent of total billed charges,,,,,,280,,,percent of total billed charges,,,,,,134.4,,,percent of total billed charges,,,,,,,,,,,,,,,165.2,,,percent of total billed charges,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,238,,,percent of total billed charges,,,,,,210,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHEATH EPS DAIG 12F  i,22972,CDM,0272,RC,,,,,,inpatient,facility,,,119,119,53.55,119,,,,,,,,,,,,,,,,,,,,101.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,83.3,,,percent of total billed charges,,,,,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,101.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.15,,,percent of total billed charges,,,,,,,,,,,,,,
SHEATH EPS DAIG 12F  i,22972,CDM,0272,RC,,,,,,outpatient,facility,,,119,119,22.61,1016,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,101.15,,,percent of total billed charges,,,,,,35.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,55.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,22.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,89.25,,,percent of total billed charges,,,,,,83.3,,,percent of total billed charges,,,,,,83.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,28.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",80.33,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,119,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,49.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",83.3,,,percent of total billed charges,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,84.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,83.3,,,percent of total billed charges,,,,,,71.4,,,percent of total billed charges,,,,,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,101.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,119,,,percent of total billed charges,,,,,,51.17,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,119,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,119,,,percent of total billed charges,,,,,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119,,,fee schedule,,,,,,119,,,percent of total billed charges,,,,,,119,,,percent of total billed charges,,,,,,119,,,percent of total billed charges,,,,,,57.12,,,percent of total billed charges,,,,,,,,,,,,,,,70.21,,,percent of total billed charges,,,,,,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,119,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,101.15,,,percent of total billed charges,,,,,,89.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE HT BMW STRT .014 X 3 X 190  c,23112,CDM,0272,RC,,,,,,inpatient,facility,,,315,315,141.75,315,,,,,,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,220.5,,,percent of total billed charges,,,,,,189,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE HT BMW STRT .014 X 3 X 190  c,23112,CDM,0272,RC,,,,,,outpatient,facility,,,315,315,59.85,1016,,204.75,,,percent of total billed charges,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,94.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,148.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,59.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,236.26,,,percent of total billed charges,,,,,,220.5,,,percent of total billed charges,,,,,,220.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,204.75,,,percent of total billed charges,,,,,,75.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",212.62,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,315,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",220.5,,,percent of total billed charges,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,,,,219.71,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,223.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,220.5,,,percent of total billed charges,,,,,,189,,,percent of total billed charges,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,,,,315,,,percent of total billed charges,,,,,,135.45,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.25,,,percent of total billed charges,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,315,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315,,,percent of total billed charges,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,fee schedule,,,,,,315,,,percent of total billed charges,,,,,,315,,,percent of total billed charges,,,,,,315,,,percent of total billed charges,,,,,,151.2,,,percent of total billed charges,,,,,,,,,,,,,,,185.85,,,percent of total billed charges,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,267.75,,,percent of total billed charges,,,,,,236.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KWIRE TROCAR POINT SYN 2.5 X 285  s,23209,CDM,0272,RC,,,,,,inpatient,facility,,,36.57,36.57,16.46,36.57,,,,,,,,,,,,,,,,,,,,31.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.6,,,percent of total billed charges,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,31.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,36.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.08,,,percent of total billed charges,,,,,,,,,,,,,,
KWIRE TROCAR POINT SYN 2.5 X 285  s,23209,CDM,0272,RC,,,,,,outpatient,facility,,,36.57,36.57,6.95,1016,,23.77,,,percent of total billed charges,,,,,,,,,,,,,,,31.08,,,percent of total billed charges,,,,,,10.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,27.42,,,percent of total billed charges,,,,,,25.6,,,percent of total billed charges,,,,,,25.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,23.77,,,percent of total billed charges,,,,,,8.78,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",24.68,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,36.57,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,15.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",25.6,,,percent of total billed charges,,,,,,,,,,,,,,,36.57,,,percent of total billed charges,,,,,,25.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,25.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.6,,,percent of total billed charges,,,,,,21.94,,,percent of total billed charges,,,,,,16.46,,,percent of total billed charges,,,,,,,,,,,,,,,31.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.57,,,percent of total billed charges,,,,,,36.57,,,percent of total billed charges,,,,,,15.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,36.57,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,36.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.43,,,percent of total billed charges,,,,,,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.57,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.57,,,percent of total billed charges,,,,,,16.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.57,,,fee schedule,,,,,,36.57,,,percent of total billed charges,,,,,,36.57,,,percent of total billed charges,,,,,,36.57,,,percent of total billed charges,,,,,,17.55,,,percent of total billed charges,,,,,,,,,,,,,,,21.58,,,percent of total billed charges,,,,,,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,36.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,31.08,,,percent of total billed charges,,,,,,27.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE SYN TH TROCAR POINT 2.8MM,23210,CDM,0272,RC,,,,,,inpatient,facility,,,127.26,127.26,57.27,127.26,,,,,,,,,,,,,,,,,,,,108.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.08,,,percent of total billed charges,,,,,,76.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,127.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,57.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,108.17,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE SYN TH TROCAR POINT 2.8MM,23210,CDM,0272,RC,,,,,,outpatient,facility,,,127.26,127.26,24.18,1016,,82.72,,,percent of total billed charges,,,,,,,,,,,,,,,108.17,,,percent of total billed charges,,,,,,38.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,24.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,95.44,,,percent of total billed charges,,,,,,89.08,,,percent of total billed charges,,,,,,89.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,82.72,,,percent of total billed charges,,,,,,30.54,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",85.9,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,127.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,53.45,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",89.08,,,percent of total billed charges,,,,,,,,,,,,,,,127.26,,,percent of total billed charges,,,,,,88.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,90.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.08,,,percent of total billed charges,,,,,,76.36,,,percent of total billed charges,,,,,,57.27,,,percent of total billed charges,,,,,,,,,,,,,,,108.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.26,,,percent of total billed charges,,,,,,127.26,,,percent of total billed charges,,,,,,54.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,127.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,127.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.44,,,percent of total billed charges,,,,,,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,127.26,,,percent of total billed charges,,,,,,57.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.26,,,fee schedule,,,,,,127.26,,,percent of total billed charges,,,,,,127.26,,,percent of total billed charges,,,,,,127.26,,,percent of total billed charges,,,,,,61.08,,,percent of total billed charges,,,,,,,,,,,,,,,75.08,,,percent of total billed charges,,,,,,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,127.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.17,,,percent of total billed charges,,,,,,95.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SYN HUM SOLID TI STRL 9.5 X 250,23213,CDM,0278,RC,,,,,,inpatient,facility,,,3403.2,3403.2,1531.44,3403.2,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2892.72,,,percent of total billed charges,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2722.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2552.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1871.76,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2057.23,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2416.27,,,percent of total billed charges,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2382.24,,,percent of total billed charges,,,,,,2041.92,,,percent of total billed charges,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2892.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.76,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3403.2,,,percent of total billed charges,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2552.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3403.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1531.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2892.72,,,percent of total billed charges,,,,,,2212.08,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SYN HUM SOLID TI STRL 9.5 X 250,23213,CDM,0278,RC,,,,,,outpatient,facility,,,3403.2,3403.2,129.72,3403.2,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2892.72,,,percent of total billed charges,,,,,,1020.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,646.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,646.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2552.4,,,percent of total billed charges,,,,,,2382.24,,,percent of total billed charges,,,,,,2382.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2212.08,,,percent of total billed charges,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3403.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2382.24,,,percent of total billed charges,,,,,,1871.76,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3403.2,,,percent of total billed charges,,,,,,2373.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2416.27,,,percent of total billed charges,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2382.24,,,percent of total billed charges,,,,,,2041.92,,,percent of total billed charges,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2892.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1871.76,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3403.2,,,percent of total billed charges,,,,,,3403.2,,,percent of total billed charges,,,,,,1871.76,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3403.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3403.2,,,percent of total billed charges,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2552.4,,,percent of total billed charges,,,,,,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3403.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3403.2,,,percent of total billed charges,,,,,,1531.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2552.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3403.2,,,fee schedule,,,,,,3403.2,,,percent of total billed charges,,,,,,3403.2,,,percent of total billed charges,,,,,,3403.2,,,percent of total billed charges,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1871.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3403.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2892.72,,,percent of total billed charges,,,,,,2552.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE HT BMW STRT .014 X 3 X 300  c,23317,CDM,0272,RC,,,,,,inpatient,facility,,,315,315,141.75,315,,,,,,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,220.5,,,percent of total billed charges,,,,,,189,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE HT BMW STRT .014 X 3 X 300  c,23317,CDM,0272,RC,,,,,,outpatient,facility,,,315,315,59.85,1016,,204.75,,,percent of total billed charges,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,94.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,148.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,59.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,236.26,,,percent of total billed charges,,,,,,220.5,,,percent of total billed charges,,,,,,220.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,204.75,,,percent of total billed charges,,,,,,75.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",212.62,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,315,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",220.5,,,percent of total billed charges,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,,,,219.71,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,223.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,220.5,,,percent of total billed charges,,,,,,189,,,percent of total billed charges,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,,,,315,,,percent of total billed charges,,,,,,135.45,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.25,,,percent of total billed charges,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,315,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315,,,percent of total billed charges,,,,,,141.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315,,,fee schedule,,,,,,315,,,percent of total billed charges,,,,,,315,,,percent of total billed charges,,,,,,315,,,percent of total billed charges,,,,,,151.2,,,percent of total billed charges,,,,,,,,,,,,,,,185.85,,,percent of total billed charges,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,315,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,267.75,,,percent of total billed charges,,,,,,236.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
RESTRICTOR DEP CEMENT FEM SZ3,23388,CDM,0278,RC,,,,,,inpatient,facility,,,120.4,120.4,54.18,120.4,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,90.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.78,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",85.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.28,,,percent of total billed charges,,,,,,72.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,78.26,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
RESTRICTOR DEP CEMENT FEM SZ3,23388,CDM,0278,RC,,,,,,outpatient,facility,,,120.4,120.4,22.88,138.8,,78.26,,,percent of total billed charges,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,36.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,56.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,90.3,,,percent of total billed charges,,,,,,84.28,,,percent of total billed charges,,,,,,84.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,78.26,,,percent of total billed charges,,,,,,28.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,120.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,50.57,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",84.28,,,percent of total billed charges,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,83.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,85.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.28,,,percent of total billed charges,,,,,,72.24,,,percent of total billed charges,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,51.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,,percent of total billed charges,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,fee schedule,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,102.34,,,percent of total billed charges,,,,,,90.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 52MM NC,23394,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 52MM NC,23394,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BLADE ZIM SAW GIGLI 12IN  i,23511,CDM,0272,RC,,,,,,inpatient,facility,,,74.93,74.93,33.72,74.93,,,,,,,,,,,,,,,,,,,,63.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.45,,,percent of total billed charges,,,,,,44.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,74.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,33.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.69,,,percent of total billed charges,,,,,,,,,,,,,,
BLADE ZIM SAW GIGLI 12IN  i,23511,CDM,0272,RC,,,,,,outpatient,facility,,,74.93,74.93,14.24,1016,,48.7,,,percent of total billed charges,,,,,,,,,,,,,,,63.69,,,percent of total billed charges,,,,,,22.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,56.2,,,percent of total billed charges,,,,,,52.45,,,percent of total billed charges,,,,,,52.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,48.7,,,percent of total billed charges,,,,,,17.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",50.58,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,74.93,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,31.47,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",52.45,,,percent of total billed charges,,,,,,,,,,,,,,,74.93,,,percent of total billed charges,,,,,,52.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.45,,,percent of total billed charges,,,,,,44.96,,,percent of total billed charges,,,,,,33.72,,,percent of total billed charges,,,,,,,,,,,,,,,63.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.93,,,percent of total billed charges,,,,,,74.93,,,percent of total billed charges,,,,,,32.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,74.93,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,74.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.2,,,percent of total billed charges,,,,,,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.93,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.93,,,percent of total billed charges,,,,,,33.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.93,,,fee schedule,,,,,,74.93,,,percent of total billed charges,,,,,,74.93,,,percent of total billed charges,,,,,,74.93,,,percent of total billed charges,,,,,,35.97,,,percent of total billed charges,,,,,,,,,,,,,,,44.21,,,percent of total billed charges,,,,,,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,74.93,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,63.69,,,percent of total billed charges,,,,,,56.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CAP SYN PROTECTIVE F RODS 8.0MM  s,23512,CDM,0272,RC,,,,,,inpatient,facility,,,13.09,13.09,5.89,13.09,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,7.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,
CAP SYN PROTECTIVE F RODS 8.0MM  s,23512,CDM,0272,RC,,,,,,outpatient,facility,,,13.09,13.09,2.49,1016,,8.51,,,percent of total billed charges,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,,,,3.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,2.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,9.82,,,percent of total billed charges,,,,,,9.16,,,percent of total billed charges,,,,,,9.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8.51,,,percent of total billed charges,,,,,,3.14,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",8.84,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13.09,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.5,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",9.16,,,percent of total billed charges,,,,,,,,,,,,,,,13.09,,,percent of total billed charges,,,,,,9.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,9.16,,,percent of total billed charges,,,,,,7.85,,,percent of total billed charges,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,11.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.09,,,percent of total billed charges,,,,,,13.09,,,percent of total billed charges,,,,,,5.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,13.09,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13.09,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13.09,,,percent of total billed charges,,,,,,5.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.09,,,fee schedule,,,,,,13.09,,,percent of total billed charges,,,,,,13.09,,,percent of total billed charges,,,,,,13.09,,,percent of total billed charges,,,,,,6.28,,,percent of total billed charges,,,,,,,,,,,,,,,7.72,,,percent of total billed charges,,,,,,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13.09,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11.13,,,percent of total billed charges,,,,,,9.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN SCHANZ SS SD 4.0 3.0 X 80,23513,CDM,0278,RC,,,,,,inpatient,facility,,,315.92,315.92,142.16,315.92,,,,,,,,,,,,,,,,,,,,268.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,236.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",224.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,221.14,,,percent of total billed charges,,,,,,189.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,268.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,315.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,142.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.53,,,percent of total billed charges,,,,,,205.35,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN SCHANZ SS SD 4.0 3.0 X 80,23513,CDM,0278,RC,,,,,,outpatient,facility,,,315.92,315.92,60.02,315.92,,205.35,,,percent of total billed charges,,,,,,,,,,,,,,,268.53,,,percent of total billed charges,,,,,,94.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,148.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,60.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,173.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,173.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,173.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,236.94,,,percent of total billed charges,,,,,,221.14,,,percent of total billed charges,,,,,,221.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,205.35,,,percent of total billed charges,,,,,,75.82,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,315.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.69,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",221.14,,,percent of total billed charges,,,,,,,,,,,,,,,315.92,,,percent of total billed charges,,,,,,220.35,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,224.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,221.14,,,percent of total billed charges,,,,,,189.55,,,percent of total billed charges,,,,,,142.16,,,percent of total billed charges,,,,,,,,,,,,,,,268.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.92,,,percent of total billed charges,,,,,,315.92,,,percent of total billed charges,,,,,,135.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,315.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,315.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.94,,,percent of total billed charges,,,,,,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,315.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,315.92,,,percent of total billed charges,,,,,,142.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.92,,,fee schedule,,,,,,315.92,,,percent of total billed charges,,,,,,315.92,,,percent of total billed charges,,,,,,315.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,315.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,268.53,,,percent of total billed charges,,,,,,236.94,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD SYN CARBON FIBER 8.0 X 220,23514,CDM,0272,RC,,,,,,inpatient,facility,,,537.46,537.46,241.86,537.46,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,381.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,376.22,,,percent of total billed charges,,,,,,322.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,
ROD SYN CARBON FIBER 8.0 X 220,23514,CDM,0272,RC,,,,,,outpatient,facility,,,537.46,537.46,102.12,1016,,349.35,,,percent of total billed charges,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,161.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,252.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,102.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,102.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,403.1,,,percent of total billed charges,,,,,,376.22,,,percent of total billed charges,,,,,,376.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,349.35,,,percent of total billed charges,,,,,,128.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",362.79,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,537.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,225.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",376.22,,,percent of total billed charges,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,374.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,381.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,376.22,,,percent of total billed charges,,,,,,322.48,,,percent of total billed charges,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,231.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,,percent of total billed charges,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,fee schedule,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,257.98,,,percent of total billed charges,,,,,,,,,,,,,,,317.1,,,percent of total billed charges,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,456.84,,,percent of total billed charges,,,,,,403.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CLAMP SYN ADJUST F DR FIXATOR MR SAFE 4.0MM,23515,CDM,0272,RC,,,,,,inpatient,facility,,,2741.2,2741.2,1233.54,2741.2,,,,,,,,,,,,,,,,,,,,2330.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2055.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1781.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1918.84,,,percent of total billed charges,,,,,,1644.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2330.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2741.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2055.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2741.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1233.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2330.02,,,percent of total billed charges,,,,,,,,,,,,,,
CLAMP SYN ADJUST F DR FIXATOR MR SAFE 4.0MM,23515,CDM,0272,RC,,,,,,outpatient,facility,,,2741.2,2741.2,129.72,2741.2,,1781.78,,,percent of total billed charges,,,,,,,,,,,,,,,2330.02,,,percent of total billed charges,,,,,,822.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1288.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,520.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,520.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2055.9,,,percent of total billed charges,,,,,,1918.84,,,percent of total billed charges,,,,,,1918.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1781.78,,,percent of total billed charges,,,,,,657.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1850.31,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2741.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1151.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1918.84,,,percent of total billed charges,,,,,,,,,,,,,,,2741.2,,,percent of total billed charges,,,,,,1911.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1946.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1918.84,,,percent of total billed charges,,,,,,1644.72,,,percent of total billed charges,,,,,,1233.54,,,percent of total billed charges,,,,,,,,,,,,,,,2330.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2741.2,,,percent of total billed charges,,,,,,2741.2,,,percent of total billed charges,,,,,,1178.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,2741.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2741.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2055.9,,,percent of total billed charges,,,,,,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2741.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2741.2,,,percent of total billed charges,,,,,,1233.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2055.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2741.2,,,fee schedule,,,,,,2741.2,,,percent of total billed charges,,,,,,2741.2,,,percent of total billed charges,,,,,,2741.2,,,percent of total billed charges,,,,,,1315.78,,,percent of total billed charges,,,,,,,,,,,,,,,1617.31,,,percent of total billed charges,,,,,,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2741.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2330.02,,,percent of total billed charges,,,,,,2055.9,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NUT DEP OUTER MOSS MIAMI TI,23518,CDM,0278,RC,,,,,,inpatient,facility,,,140,140,63,140,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,105,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.63,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",99.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98,,,percent of total billed charges,,,,,,84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,140,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NUT DEP OUTER MOSS MIAMI TI,23518,CDM,0278,RC,,,,,,outpatient,facility,,,140,140,26.6,140,,91,,,percent of total billed charges,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,26.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,105,,,percent of total billed charges,,,,,,98,,,percent of total billed charges,,,,,,98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,33.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,140,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.8,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",98,,,percent of total billed charges,,,,,,,,,,,,,,,140,,,percent of total billed charges,,,,,,97.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,99.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98,,,percent of total billed charges,,,,,,84,,,percent of total billed charges,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,,percent of total billed charges,,,,,,140,,,percent of total billed charges,,,,,,60.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,140,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,140,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140,,,percent of total billed charges,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,,fee schedule,,,,,,140,,,percent of total billed charges,,,,,,140,,,percent of total billed charges,,,,,,140,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,119,,,percent of total billed charges,,,,,,105,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR DEP INNER MOSS MIAMI TI,23519,CDM,0278,RC,,,,,,inpatient,facility,,,140,140,63,140,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,105,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.63,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",99.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98,,,percent of total billed charges,,,,,,84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,140,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR DEP INNER MOSS MIAMI TI,23519,CDM,0278,RC,,,,,,outpatient,facility,,,140,140,26.6,140,,91,,,percent of total billed charges,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,65.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,26.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,77,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,105,,,percent of total billed charges,,,,,,98,,,percent of total billed charges,,,,,,98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,33.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,140,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.8,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",98,,,percent of total billed charges,,,,,,,,,,,,,,,140,,,percent of total billed charges,,,,,,97.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,99.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98,,,percent of total billed charges,,,,,,84,,,percent of total billed charges,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,119,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,,percent of total billed charges,,,,,,140,,,percent of total billed charges,,,,,,60.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,140,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,140,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,140,,,percent of total billed charges,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,,fee schedule,,,,,,140,,,percent of total billed charges,,,,,,140,,,percent of total billed charges,,,,,,140,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,140,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,119,,,percent of total billed charges,,,,,,105,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
KIT INFLATION DEVICE ENCORE 26 ADVANTAGE 20ML  i,23572,CDM,0272,RC,,,,,,inpatient,facility,,,105,105,47.25,105,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,73.5,,,percent of total billed charges,,,,,,63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,105,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,47.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,,,,,,,
KIT INFLATION DEVICE ENCORE 26 ADVANTAGE 20ML  i,23572,CDM,0272,RC,,,,,,outpatient,facility,,,105,105,19.95,1016,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,31.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,19.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,19.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,78.75,,,percent of total billed charges,,,,,,73.5,,,percent of total billed charges,,,,,,73.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,25.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",70.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,105,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,44.1,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",73.5,,,percent of total billed charges,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,73.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,74.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,73.5,,,percent of total billed charges,,,,,,63,,,percent of total billed charges,,,,,,47.25,,,percent of total billed charges,,,,,,,,,,,,,,,89.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,105,,,percent of total billed charges,,,,,,45.15,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,105,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.75,,,percent of total billed charges,,,,,,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,105,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,105,,,percent of total billed charges,,,,,,47.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105,,,fee schedule,,,,,,105,,,percent of total billed charges,,,,,,105,,,percent of total billed charges,,,,,,105,,,percent of total billed charges,,,,,,50.4,,,percent of total billed charges,,,,,,,,,,,,,,,61.95,,,percent of total billed charges,,,,,,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,105,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,89.25,,,percent of total billed charges,,,,,,78.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEMOSTAT SURGICEL FIBRILLAR  i,23579,CDM,0272,RC,,,,,,inpatient,facility,,,288.31,288.31,129.74,288.31,,,,,,,,,,,,,,,,,,,,245.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,204.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,201.82,,,percent of total billed charges,,,,,,172.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,245.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,288.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,129.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,245.06,,,percent of total billed charges,,,,,,,,,,,,,,
HEMOSTAT SURGICEL FIBRILLAR  i,23579,CDM,0272,RC,,,,,,outpatient,facility,,,288.31,288.31,54.78,1016,,187.4,,,percent of total billed charges,,,,,,,,,,,,,,,245.06,,,percent of total billed charges,,,,,,86.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,54.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,216.23,,,percent of total billed charges,,,,,,201.82,,,percent of total billed charges,,,,,,201.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,187.4,,,percent of total billed charges,,,,,,69.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",194.61,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,288.31,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,121.09,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",201.82,,,percent of total billed charges,,,,,,,,,,,,,,,288.31,,,percent of total billed charges,,,,,,201.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,204.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,201.82,,,percent of total billed charges,,,,,,172.99,,,percent of total billed charges,,,,,,129.74,,,percent of total billed charges,,,,,,,,,,,,,,,245.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.31,,,percent of total billed charges,,,,,,288.31,,,percent of total billed charges,,,,,,123.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,288.31,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,288.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.23,,,percent of total billed charges,,,,,,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,288.31,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,288.31,,,percent of total billed charges,,,,,,129.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.31,,,fee schedule,,,,,,288.31,,,percent of total billed charges,,,,,,288.31,,,percent of total billed charges,,,,,,288.31,,,percent of total billed charges,,,,,,138.39,,,percent of total billed charges,,,,,,,,,,,,,,,170.1,,,percent of total billed charges,,,,,,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,288.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,245.06,,,percent of total billed charges,,,,,,216.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 30,23731,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 30,23731,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 32,23732,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 32,23732,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 34,23733,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 34,23733,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 38,23734,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 38,23734,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 40,23735,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 40,23735,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 42,23736,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 42,23736,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 44,23737,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 44,23737,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRSG TEGADERM TRANSP STRL 4 X 10,23738,CDM,0272,RC,,,,,,inpatient,facility,,,3.62,3.62,1.63,3.62,,,,,,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,2.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,
DRSG TEGADERM TRANSP STRL 4 X 10,23738,CDM,0272,RC,,,,,,outpatient,facility,,,3.62,3.62,0.69,1016,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,1.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2.71,,,percent of total billed charges,,,,,,2.53,,,percent of total billed charges,,,,,,2.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,0.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.44,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3.62,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.52,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.53,,,percent of total billed charges,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,2.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.53,,,percent of total billed charges,,,,,,2.17,,,percent of total billed charges,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,3.62,,,percent of total billed charges,,,,,,1.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.72,,,percent of total billed charges,,,,,,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.62,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3.62,,,percent of total billed charges,,,,,,1.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.62,,,fee schedule,,,,,,3.62,,,percent of total billed charges,,,,,,3.62,,,percent of total billed charges,,,,,,3.62,,,percent of total billed charges,,,,,,1.74,,,percent of total billed charges,,,,,,,,,,,,,,,2.14,,,percent of total billed charges,,,,,,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3.62,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.08,,,percent of total billed charges,,,,,,2.71,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRSG TEGADERM TRANSP STRL 6 X 8  i,23741,CDM,0272,RC,,,,,,inpatient,facility,,,4.12,4.12,1.85,4.12,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,2.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,
DRSG TEGADERM TRANSP STRL 6 X 8  i,23741,CDM,0272,RC,,,,,,outpatient,facility,,,4.12,4.12,0.78,1016,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,1.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.09,,,percent of total billed charges,,,,,,2.88,,,percent of total billed charges,,,,,,2.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,0.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.78,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2.88,,,percent of total billed charges,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,2.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2.88,,,percent of total billed charges,,,,,,2.47,,,percent of total billed charges,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,4.12,,,percent of total billed charges,,,,,,1.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.12,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.12,,,percent of total billed charges,,,,,,1.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.12,,,fee schedule,,,,,,4.12,,,percent of total billed charges,,,,,,4.12,,,percent of total billed charges,,,,,,4.12,,,percent of total billed charges,,,,,,1.98,,,percent of total billed charges,,,,,,,,,,,,,,,2.43,,,percent of total billed charges,,,,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.5,,,percent of total billed charges,,,,,,3.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS SHRT TH 4.0 X 46,23814,CDM,0278,RC,,,,,,inpatient,facility,,,302.4,302.4,136.08,302.4,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,226.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,196.56,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS SHRT TH 4.0 X 46,23814,CDM,0278,RC,,,,,,outpatient,facility,,,302.4,302.4,57.46,302.4,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,90.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.8,,,percent of total billed charges,,,,,,211.68,,,percent of total billed charges,,,,,,211.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,196.56,,,percent of total billed charges,,,,,,72.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,302.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.01,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",211.68,,,percent of total billed charges,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,210.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,211.68,,,percent of total billed charges,,,,,,181.44,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,257.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,130.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,302.4,,,percent of total billed charges,,,,,,136.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,,fee schedule,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,302.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,302.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.04,,,percent of total billed charges,,,,,,226.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 30,23860,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 30,23860,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 35,23861,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 35,23861,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 40,23862,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 40,23862,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 45,23863,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 45,23863,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 50,23864,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 50,23864,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 55,23865,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 55,23865,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 60,23866,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 60,23866,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 65,23867,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 65,23867,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 70,23868,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 70,23868,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 75,23869,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 75,23869,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 80,23870,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 80,23870,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 85,23871,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 85,23871,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 90,23872,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 90,23872,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 95,23873,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 95,23873,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 100,23874,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 100,23874,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 105,23875,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 105,23875,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 110,23876,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 110,23876,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 115,23877,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 115,23877,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 120,23878,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 120,23878,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 125,23879,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 125,23879,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 16 X 130,23880,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 16 X 130,23880,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD SYN CARBON FIBER 8.0 X 200,23966,CDM,0272,RC,,,,,,inpatient,facility,,,537.46,537.46,241.86,537.46,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,381.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,376.22,,,percent of total billed charges,,,,,,322.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,
ROD SYN CARBON FIBER 8.0 X 200,23966,CDM,0272,RC,,,,,,outpatient,facility,,,537.46,537.46,102.12,1016,,349.35,,,percent of total billed charges,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,161.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,252.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,102.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,102.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,403.1,,,percent of total billed charges,,,,,,376.22,,,percent of total billed charges,,,,,,376.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,349.35,,,percent of total billed charges,,,,,,128.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",362.79,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,537.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,225.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",376.22,,,percent of total billed charges,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,374.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,381.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,376.22,,,percent of total billed charges,,,,,,322.48,,,percent of total billed charges,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,231.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,,percent of total billed charges,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,fee schedule,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,257.98,,,percent of total billed charges,,,,,,,,,,,,,,,317.1,,,percent of total billed charges,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,456.84,,,percent of total billed charges,,,,,,403.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD SYN CARBON FIBER 8.0 X 240,23967,CDM,0272,RC,,,,,,inpatient,facility,,,537.46,537.46,241.86,537.46,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,381.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,376.22,,,percent of total billed charges,,,,,,322.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,
ROD SYN CARBON FIBER 8.0 X 240,23967,CDM,0272,RC,,,,,,outpatient,facility,,,537.46,537.46,102.12,1016,,349.35,,,percent of total billed charges,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,161.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,252.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,102.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,102.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,403.1,,,percent of total billed charges,,,,,,376.22,,,percent of total billed charges,,,,,,376.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,349.35,,,percent of total billed charges,,,,,,128.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",362.79,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,537.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,225.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",376.22,,,percent of total billed charges,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,374.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,381.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,376.22,,,percent of total billed charges,,,,,,322.48,,,percent of total billed charges,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,456.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,231.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,537.46,,,percent of total billed charges,,,,,,241.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,537.46,,,fee schedule,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,537.46,,,percent of total billed charges,,,,,,257.98,,,percent of total billed charges,,,,,,,,,,,,,,,317.1,,,percent of total billed charges,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,537.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,456.84,,,percent of total billed charges,,,,,,403.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 26   0 NC,23986,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 26   0 NC,23986,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 26   5 NC,23987,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 26   5 NC,23987,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 26   10 NC,23988,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 26   10 NC,23988,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 28 X 10 X 54,24204,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 28 X 10 X 54,24204,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 100 54MM,24205,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 100 54MM,24205,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE SYN TH 1.6 X 150,24210,CDM,0272,RC,,,,,,inpatient,facility,,,93.24,93.24,41.96,93.24,,,,,,,,,,,,,,,,,,,,79.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,55.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,79.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,93.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,41.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.25,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE SYN TH 1.6 X 150,24210,CDM,0272,RC,,,,,,outpatient,facility,,,93.24,93.24,17.72,1016,,60.61,,,percent of total billed charges,,,,,,,,,,,,,,,79.25,,,percent of total billed charges,,,,,,27.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,17.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,69.93,,,percent of total billed charges,,,,,,65.27,,,percent of total billed charges,,,,,,65.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,60.61,,,percent of total billed charges,,,,,,22.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",62.94,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,93.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",65.27,,,percent of total billed charges,,,,,,,,,,,,,,,93.24,,,percent of total billed charges,,,,,,65.03,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,66.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.27,,,percent of total billed charges,,,,,,55.94,,,percent of total billed charges,,,,,,41.96,,,percent of total billed charges,,,,,,,,,,,,,,,79.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.24,,,percent of total billed charges,,,,,,93.24,,,percent of total billed charges,,,,,,40.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,93.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,93.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.93,,,percent of total billed charges,,,,,,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.24,,,percent of total billed charges,,,,,,41.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.24,,,fee schedule,,,,,,93.24,,,percent of total billed charges,,,,,,93.24,,,percent of total billed charges,,,,,,93.24,,,percent of total billed charges,,,,,,44.76,,,percent of total billed charges,,,,,,,,,,,,,,,55.01,,,percent of total billed charges,,,,,,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,93.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,79.25,,,percent of total billed charges,,,,,,69.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC CANN 3.2 X 170,24212,CDM,0272,RC,,,,,,inpatient,facility,,,1179.36,1179.36,530.71,1179.36,,,,,,,,,,,,,,,,,,,,1002.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,837.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,825.55,,,percent of total billed charges,,,,,,707.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1002.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1179.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1179.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,530.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1002.46,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC CANN 3.2 X 170,24212,CDM,0272,RC,,,,,,outpatient,facility,,,1179.36,1179.36,129.72,1179.36,,766.58,,,percent of total billed charges,,,,,,,,,,,,,,,1002.46,,,percent of total billed charges,,,,,,353.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,554.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,224.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,224.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,884.52,,,percent of total billed charges,,,,,,825.55,,,percent of total billed charges,,,,,,825.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,766.58,,,percent of total billed charges,,,,,,283.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",796.07,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1179.36,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,495.33,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",825.55,,,percent of total billed charges,,,,,,,,,,,,,,,1179.36,,,percent of total billed charges,,,,,,822.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,837.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,825.55,,,percent of total billed charges,,,,,,707.62,,,percent of total billed charges,,,,,,530.71,,,percent of total billed charges,,,,,,,,,,,,,,,1002.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1179.36,,,percent of total billed charges,,,,,,1179.36,,,percent of total billed charges,,,,,,507.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1179.36,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1179.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.52,,,percent of total billed charges,,,,,,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1179.36,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1179.36,,,percent of total billed charges,,,,,,530.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1179.36,,,fee schedule,,,,,,1179.36,,,percent of total billed charges,,,,,,1179.36,,,percent of total billed charges,,,,,,1179.36,,,percent of total billed charges,,,,,,566.09,,,percent of total billed charges,,,,,,,,,,,,,,,695.82,,,percent of total billed charges,,,,,,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1179.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1002.46,,,percent of total billed charges,,,,,,884.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 32   0 NC,24234,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 32   0 NC,24234,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 32   5 NC,24235,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 32   5 NC,24235,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD STR HIP C TAPER COCR 32   10 NC,24237,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD STR HIP C TAPER COCR 32   10 NC,24237,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATCH HEMA PLATINUM FINESE 8 X 75  i,24475,CDM,0278,RC,,,,,,inpatient,facility,,,230.94,230.94,103.92,230.94,,,,,,,,,,,,,,,,,,,,196.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,184.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,173.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",163.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,161.66,,,percent of total billed charges,,,,,,138.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,196.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,230.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,103.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.3,,,percent of total billed charges,,,,,,150.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATCH HEMA PLATINUM FINESE 8 X 75  i,24475,CDM,0278,RC,,,,,,outpatient,facility,,,230.94,230.94,43.88,230.94,,150.11,,,percent of total billed charges,,,,,,,,,,,,,,,196.3,,,percent of total billed charges,,,,,,69.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,108.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,43.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,127.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,127.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,127.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,173.2,,,percent of total billed charges,,,,,,161.66,,,percent of total billed charges,,,,,,161.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,150.11,,,percent of total billed charges,,,,,,55.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,230.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,96.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",161.66,,,percent of total billed charges,,,,,,,,,,,,,,,230.94,,,percent of total billed charges,,,,,,161.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,163.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,161.66,,,percent of total billed charges,,,,,,138.56,,,percent of total billed charges,,,,,,103.92,,,percent of total billed charges,,,,,,,,,,,,,,,196.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.94,,,percent of total billed charges,,,,,,230.94,,,percent of total billed charges,,,,,,99.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,230.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,230.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.2,,,percent of total billed charges,,,,,,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,230.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,230.94,,,percent of total billed charges,,,,,,103.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.94,,,fee schedule,,,,,,230.94,,,percent of total billed charges,,,,,,230.94,,,percent of total billed charges,,,,,,230.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,230.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,196.3,,,percent of total billed charges,,,,,,173.21,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP DHS SS 95DG 6H 25 X 114,24520,CDM,0278,RC,,,,,,inpatient,facility,,,2220,2220,999,2220,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1887,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1776,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1665,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1221,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1341.99,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1576.2,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1554,,,percent of total billed charges,,,,,,1332,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1887,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,999,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1887,,,percent of total billed charges,,,,,,1443,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP DHS SS 95DG 6H 25 X 114,24520,CDM,0278,RC,,,,,,outpatient,facility,,,2220,2220,129.72,2220,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1887,,,percent of total billed charges,,,,,,666,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,421.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,421.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1665,,,percent of total billed charges,,,,,,1554,,,percent of total billed charges,,,,,,1554,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1443,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1554,,,percent of total billed charges,,,,,,1221,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,1548.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1576.2,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1554,,,percent of total billed charges,,,,,,1332,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1887,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,,percent of total billed charges,,,,,,999,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2220,,,fee schedule,,,,,,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1887,,,percent of total billed charges,,,,,,1665,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD ZIM HIP FEM COCR 12 14 28   3.5 NC,24523,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD ZIM HIP FEM COCR 12 14 28   3.5 NC,24523,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP DEP HIP SECTOR DURALOC 54MM,24532,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP DEP HIP SECTOR DURALOC 54MM,24532,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP FEM ARTICUL EZE STD 28   5.0 NC,24534,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP FEM ARTICUL EZE STD 28   5.0 NC,24534,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 28 X 10 X 60,24535,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 28 X 10 X 60,24535,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL DEP HIP DURALOC 100 60MM,24536,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL DEP HIP DURALOC 100 60MM,24536,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP ENDURON 26 X 10 X 48,24606,CDM,0278,RC,,,,,,inpatient,facility,,,910,910,409.5,910,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,682.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,550.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,591.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP ENDURON 26 X 10 X 48,24606,CDM,0278,RC,,,,,,outpatient,facility,,,910,910,129.72,910,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,273,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,427.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,682.5,,,percent of total billed charges,,,,,,637,,,percent of total billed charges,,,,,,637,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,591.5,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,910,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,500.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,634.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,646.1,,,percent of total billed charges,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637,,,percent of total billed charges,,,,,,546,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,,percent of total billed charges,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,910,,,percent of total billed charges,,,,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,500.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,910,,,fee schedule,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,910,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,773.5,,,percent of total billed charges,,,,,,682.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INSERT DEP TIBIA PFC STAB 3 X 12.5,24611,CDM,0278,RC,,,,,,inpatient,facility,,,1360,1360,612,1360,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1156,,,percent of total billed charges,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1020,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,748,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,822.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",965.6,,,percent of total billed charges,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,952,,,percent of total billed charges,,,,,,816,,,percent of total billed charges,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1156,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1360,,,percent of total billed charges,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1020,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,612,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1156,,,percent of total billed charges,,,,,,884,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
INSERT DEP TIBIA PFC STAB 3 X 12.5,24611,CDM,0278,RC,,,,,,outpatient,facility,,,1360,1360,129.72,1360,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1156,,,percent of total billed charges,,,,,,408,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,258.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,258.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1020,,,percent of total billed charges,,,,,,952,,,percent of total billed charges,,,,,,952,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,884,,,percent of total billed charges,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,952,,,percent of total billed charges,,,,,,748,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1360,,,percent of total billed charges,,,,,,948.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,965.6,,,percent of total billed charges,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,952,,,percent of total billed charges,,,,,,816,,,percent of total billed charges,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1156,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,748,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1360,,,percent of total billed charges,,,,,,1360,,,percent of total billed charges,,,,,,748,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1360,,,percent of total billed charges,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1020,,,percent of total billed charges,,,,,,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1360,,,percent of total billed charges,,,,,,612,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1020,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1360,,,fee schedule,,,,,,1360,,,percent of total billed charges,,,,,,1360,,,percent of total billed charges,,,,,,1360,,,percent of total billed charges,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,748,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1156,,,percent of total billed charges,,,,,,1020,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 49MM NC,24700,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 49MM NC,24700,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 42MM NC,24701,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 42MM NC,24701,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 43MM NC,24702,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 43MM NC,24702,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 44MM NC,24703,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 44MM NC,24703,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 48MM NC,24706,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 48MM NC,24706,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 51MM NC,24707,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 51MM NC,24707,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 56MM NC,24712,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 56MM NC,24712,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 58MM NC,24714,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 58MM NC,24714,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP UNIPOLAR 60MM NC,24716,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP UNIPOLAR 60MM NC,24716,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP HIP SOL STND 13.5 X 8,24717,CDM,0278,RC,,,,,,inpatient,facility,,,8590,8590,3865.5,8590,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,7301.5,,,percent of total billed charges,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6872,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6442.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4724.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5192.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",6098.9,,,percent of total billed charges,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,6013,,,percent of total billed charges,,,,,,5154,,,percent of total billed charges,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,7301.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4724.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4724.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8590,,,percent of total billed charges,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,6442.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,8590,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3865.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4724.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7301.5,,,percent of total billed charges,,,,,,5583.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP HIP SOL STND 13.5 X 8,24717,CDM,0278,RC,,,,,,outpatient,facility,,,8590,8590,129.72,8590,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,7301.5,,,percent of total billed charges,,,,,,2577,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1632.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1632.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6442.5,,,percent of total billed charges,,,,,,6013,,,percent of total billed charges,,,,,,6013,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,5583.5,,,percent of total billed charges,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,8590,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6013,,,percent of total billed charges,,,,,,4724.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,8590,,,percent of total billed charges,,,,,,5991.53,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,6098.9,,,percent of total billed charges,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,6013,,,percent of total billed charges,,,,,,5154,,,percent of total billed charges,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,7301.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4724.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4724.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,8590,,,percent of total billed charges,,,,,,8590,,,percent of total billed charges,,,,,,4724.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8590,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,8590,,,percent of total billed charges,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,6442.5,,,percent of total billed charges,,,,,,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,8590,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,8590,,,percent of total billed charges,,,,,,3865.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6442.5,,,percent of total billed charges,,,,,,4724.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,8590,,,fee schedule,,,,,,8590,,,percent of total billed charges,,,,,,8590,,,percent of total billed charges,,,,,,8590,,,percent of total billed charges,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4724.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,8590,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7301.5,,,percent of total billed charges,,,,,,6442.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
VALVE CRY AORTIC 23MM,24718,CDM,0278,RC,,,,,,inpatient,facility,,,24270,24270,10921.5,24270,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,20629.5,,,percent of total billed charges,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",13348.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19416,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,18202.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,13348.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,14671.22,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",17231.7,,,percent of total billed charges,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,16989,,,percent of total billed charges,,,,,,14562,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,20629.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13348.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24270,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,18202.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,24270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,10921.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20629.5,,,percent of total billed charges,,,,,,15775.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
VALVE CRY AORTIC 23MM,24718,CDM,0278,RC,,,,,,outpatient,facility,,,24270,24270,129.72,24270,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,20629.5,,,percent of total billed charges,,,,,,7281,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",13348.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4611.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4611.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18202.5,,,percent of total billed charges,,,,,,16989,,,percent of total billed charges,,,,,,16989,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,15775.5,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,24270,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16989,,,percent of total billed charges,,,,,,13348.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,,percent of total billed charges,,,,,,16928.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,17231.7,,,percent of total billed charges,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16989,,,percent of total billed charges,,,,,,14562,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,20629.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,13348.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13348.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,,percent of total billed charges,,,,,,24270,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24270,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,18202.5,,,percent of total billed charges,,,,,,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,24270,,,percent of total billed charges,,,,,,10921.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18202.5,,,percent of total billed charges,,,,,,13348.5,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,24270,,,fee schedule,,,,,,24270,,,percent of total billed charges,,,,,,24270,,,percent of total billed charges,,,,,,24270,,,percent of total billed charges,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,13348.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,24270,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,20629.5,,,percent of total billed charges,,,,,,18202.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INTRO FAST CATH SR0 8.5F 60CM  i,24756,CDM,0272,RC,,,,,,inpatient,facility,,,598.5,598.5,269.32,598.5,,,,,,,,,,,,,,,,,,,,508.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,389.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,418.95,,,percent of total billed charges,,,,,,359.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,508.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,269.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.72,,,percent of total billed charges,,,,,,,,,,,,,,
INTRO FAST CATH SR0 8.5F 60CM  i,24756,CDM,0272,RC,,,,,,outpatient,facility,,,598.5,598.5,113.72,1016,,389.02,,,percent of total billed charges,,,,,,,,,,,,,,,508.72,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,281.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,113.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,113.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,448.88,,,percent of total billed charges,,,,,,418.95,,,percent of total billed charges,,,,,,418.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,389.03,,,percent of total billed charges,,,,,,143.64,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",403.99,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,598.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,251.37,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",418.95,,,percent of total billed charges,,,,,,,,,,,,,,,598.5,,,percent of total billed charges,,,,,,417.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,424.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,418.95,,,percent of total billed charges,,,,,,359.1,,,percent of total billed charges,,,,,,269.32,,,percent of total billed charges,,,,,,,,,,,,,,,508.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,598.5,,,percent of total billed charges,,,,,,598.5,,,percent of total billed charges,,,,,,257.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,598.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,598.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.88,,,percent of total billed charges,,,,,,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,598.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,598.5,,,percent of total billed charges,,,,,,269.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,448.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,598.5,,,fee schedule,,,,,,598.5,,,percent of total billed charges,,,,,,598.5,,,percent of total billed charges,,,,,,598.5,,,percent of total billed charges,,,,,,287.28,,,percent of total billed charges,,,,,,,,,,,,,,,353.12,,,percent of total billed charges,,,,,,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,598.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,508.72,,,percent of total billed charges,,,,,,448.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI .76 X 6 STOP 44.5,24770,CDM,0272,RC,,,,,,inpatient,facility,,,526.75,526.75,237.04,526.75,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI .76 X 6 STOP 44.5,24770,CDM,0272,RC,,,,,,outpatient,facility,,,526.75,526.75,100.08,1016,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,158.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,247.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,395.07,,,percent of total billed charges,,,,,,368.73,,,percent of total billed charges,,,,,,368.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,126.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",355.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,221.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",368.72,,,percent of total billed charges,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,367.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,226.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,fee schedule,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,252.84,,,percent of total billed charges,,,,,,,,,,,,,,,310.78,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.74,,,percent of total billed charges,,,,,,395.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI .76 X 8 STOP 44.5,24771,CDM,0272,RC,,,,,,inpatient,facility,,,526.75,526.75,237.04,526.75,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI .76 X 8 STOP 44.5,24771,CDM,0272,RC,,,,,,outpatient,facility,,,526.75,526.75,100.08,1016,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,158.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,247.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,395.07,,,percent of total billed charges,,,,,,368.73,,,percent of total billed charges,,,,,,368.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,126.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",355.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,221.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",368.72,,,percent of total billed charges,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,367.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,226.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,fee schedule,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,252.84,,,percent of total billed charges,,,,,,,,,,,,,,,310.78,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.74,,,percent of total billed charges,,,,,,395.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI .76 X 10 STOP 44.5,24772,CDM,0272,RC,,,,,,inpatient,facility,,,526.75,526.75,237.04,526.75,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI .76 X 10 STOP 44.5,24772,CDM,0272,RC,,,,,,outpatient,facility,,,526.75,526.75,100.08,1016,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,158.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,247.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,395.07,,,percent of total billed charges,,,,,,368.73,,,percent of total billed charges,,,,,,368.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,126.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",355.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,221.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",368.72,,,percent of total billed charges,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,367.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,226.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,fee schedule,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,252.84,,,percent of total billed charges,,,,,,,,,,,,,,,310.78,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.74,,,percent of total billed charges,,,,,,395.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI .76 X 12 STOP 44.5,24773,CDM,0272,RC,,,,,,inpatient,facility,,,526.75,526.75,237.04,526.75,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI .76 X 12 STOP 44.5,24773,CDM,0272,RC,,,,,,outpatient,facility,,,526.75,526.75,100.08,1016,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,158.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,247.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,395.07,,,percent of total billed charges,,,,,,368.73,,,percent of total billed charges,,,,,,368.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,126.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",355.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,221.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",368.72,,,percent of total billed charges,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,367.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,226.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,fee schedule,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,252.84,,,percent of total billed charges,,,,,,,,,,,,,,,310.78,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.74,,,percent of total billed charges,,,,,,395.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI .76 X 14 STOP 44.5,24774,CDM,0272,RC,,,,,,inpatient,facility,,,526.75,526.75,237.04,526.75,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI .76 X 14 STOP 44.5,24774,CDM,0272,RC,,,,,,outpatient,facility,,,526.75,526.75,100.08,1016,,342.39,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,158.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,247.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,100.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,395.07,,,percent of total billed charges,,,,,,368.73,,,percent of total billed charges,,,,,,368.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,342.39,,,percent of total billed charges,,,,,,126.42,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",355.56,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,221.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",368.72,,,percent of total billed charges,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,367.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,373.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,368.72,,,percent of total billed charges,,,,,,316.05,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,447.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,226.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,526.75,,,percent of total billed charges,,,,,,237.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.75,,,fee schedule,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,526.75,,,percent of total billed charges,,,,,,252.84,,,percent of total billed charges,,,,,,,,,,,,,,,310.78,,,percent of total billed charges,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,526.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.74,,,percent of total billed charges,,,,,,395.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI 1.0 X 50,24775,CDM,0272,RC,,,,,,inpatient,facility,,,261.87,261.87,117.84,261.87,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI 1.0 X 50,24775,CDM,0272,RC,,,,,,outpatient,facility,,,261.87,261.87,49.76,1016,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,78.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,123.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,196.4,,,percent of total billed charges,,,,,,183.31,,,percent of total billed charges,,,,,,183.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,62.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",176.76,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,109.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",183.31,,,percent of total billed charges,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,182.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,112.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,fee schedule,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,125.7,,,percent of total billed charges,,,,,,,,,,,,,,,154.5,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,222.59,,,percent of total billed charges,,,,,,196.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI 1.3 X 55,24776,CDM,0272,RC,,,,,,inpatient,facility,,,261.87,261.87,117.84,261.87,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI 1.3 X 55,24776,CDM,0272,RC,,,,,,outpatient,facility,,,261.87,261.87,49.76,1016,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,78.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,123.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,196.4,,,percent of total billed charges,,,,,,183.31,,,percent of total billed charges,,,,,,183.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,62.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",176.76,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,109.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",183.31,,,percent of total billed charges,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,182.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,112.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,fee schedule,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,125.7,,,percent of total billed charges,,,,,,,,,,,,,,,154.5,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,222.59,,,percent of total billed charges,,,,,,196.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI 1.8 X 80,24777,CDM,0272,RC,,,,,,inpatient,facility,,,257.35,257.35,115.81,257.35,,,,,,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.15,,,percent of total billed charges,,,,,,154.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI 1.8 X 80,24777,CDM,0272,RC,,,,,,outpatient,facility,,,257.35,257.35,48.9,1016,,167.28,,,percent of total billed charges,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,77.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,193.01,,,percent of total billed charges,,,,,,180.15,,,percent of total billed charges,,,,,,180.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,167.28,,,percent of total billed charges,,,,,,61.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",173.71,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,257.35,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.09,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",180.15,,,percent of total billed charges,,,,,,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,179.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.15,,,percent of total billed charges,,,,,,154.41,,,percent of total billed charges,,,,,,115.81,,,percent of total billed charges,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,257.35,,,percent of total billed charges,,,,,,110.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,257.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.01,,,percent of total billed charges,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.35,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.35,,,percent of total billed charges,,,,,,115.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,,fee schedule,,,,,,257.35,,,percent of total billed charges,,,,,,257.35,,,percent of total billed charges,,,,,,257.35,,,percent of total billed charges,,,,,,123.53,,,percent of total billed charges,,,,,,,,,,,,,,,151.84,,,percent of total billed charges,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.75,,,percent of total billed charges,,,,,,193.01,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI 2.4 X 80,24778,CDM,0272,RC,,,,,,inpatient,facility,,,257.35,257.35,115.81,257.35,,,,,,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.15,,,percent of total billed charges,,,,,,154.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI 2.4 X 80,24778,CDM,0272,RC,,,,,,outpatient,facility,,,257.35,257.35,48.9,1016,,167.28,,,percent of total billed charges,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,77.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,193.01,,,percent of total billed charges,,,,,,180.15,,,percent of total billed charges,,,,,,180.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,167.28,,,percent of total billed charges,,,,,,61.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",173.71,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,257.35,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.09,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",180.15,,,percent of total billed charges,,,,,,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,179.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.15,,,percent of total billed charges,,,,,,154.41,,,percent of total billed charges,,,,,,115.81,,,percent of total billed charges,,,,,,,,,,,,,,,218.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,257.35,,,percent of total billed charges,,,,,,110.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,257.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.01,,,percent of total billed charges,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.35,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,257.35,,,percent of total billed charges,,,,,,115.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.35,,,fee schedule,,,,,,257.35,,,percent of total billed charges,,,,,,257.35,,,percent of total billed charges,,,,,,257.35,,,percent of total billed charges,,,,,,123.53,,,percent of total billed charges,,,,,,,,,,,,,,,151.84,,,percent of total billed charges,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,257.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.75,,,percent of total billed charges,,,,,,193.01,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 6,24779,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 6,24779,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 7,24780,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 7,24780,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 8,24781,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 8,24781,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 9,24782,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 9,24782,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 10,24783,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 10,24783,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 11,24784,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 11,24784,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 12,24785,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 12,24785,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 13,24786,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 13,24786,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.0 X 14,24787,CDM,0278,RC,,,,,,inpatient,facility,,,155.66,155.66,70.05,155.66,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,101.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.0 X 14,24787,CDM,0278,RC,,,,,,outpatient,facility,,,155.66,155.66,29.58,155.66,,101.18,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,46.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.61,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.74,,,percent of total billed charges,,,,,,108.96,,,percent of total billed charges,,,,,,108.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.18,,,percent of total billed charges,,,,,,37.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,155.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.96,,,percent of total billed charges,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,108.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.96,,,percent of total billed charges,,,,,,93.4,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,132.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,66.93,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.74,,,percent of total billed charges,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.66,,,percent of total billed charges,,,,,,70.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,,fee schedule,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,155.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.31,,,percent of total billed charges,,,,,,116.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 6,24788,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 6,24788,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 7,24789,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 7,24789,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 8,24790,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 8,24790,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 9,24791,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 9,24791,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 10,24792,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 10,24792,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 11,24793,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 11,24793,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 12,24794,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 12,24794,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 13,24795,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 13,24795,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 14,24796,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 14,24796,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 16,24797,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 16,24797,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.3 X 18,24798,CDM,0278,RC,,,,,,inpatient,facility,,,193.5,193.5,87.08,193.5,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,145.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.97,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,125.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.3 X 18,24798,CDM,0278,RC,,,,,,outpatient,facility,,,193.5,193.5,36.77,193.5,,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,58.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.43,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.12,,,percent of total billed charges,,,,,,135.45,,,percent of total billed charges,,,,,,135.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,125.78,,,percent of total billed charges,,,,,,46.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,193.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",135.45,,,percent of total billed charges,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,134.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,137.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,135.45,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,164.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,83.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.12,,,percent of total billed charges,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,193.5,,,percent of total billed charges,,,,,,87.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,fee schedule,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,193.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,164.48,,,percent of total billed charges,,,,,,145.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI STRT TI 6H 1.3 X 23,24799,CDM,0278,RC,,,,,,inpatient,facility,,,699.18,699.18,314.63,699.18,,,,,,,,,,,,,,,,,,,,594.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,559.34,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,524.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.65,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",496.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,489.43,,,percent of total billed charges,,,,,,419.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,594.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,384.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,699.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,314.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,594.3,,,percent of total billed charges,,,,,,454.47,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI STRT TI 6H 1.3 X 23,24799,CDM,0278,RC,,,,,,outpatient,facility,,,699.18,699.18,129.72,699.18,,454.47,,,percent of total billed charges,,,,,,,,,,,,,,,594.3,,,percent of total billed charges,,,,,,209.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,328.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,132.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,384.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,384.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,384.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,524.39,,,percent of total billed charges,,,,,,489.43,,,percent of total billed charges,,,,,,489.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,454.47,,,percent of total billed charges,,,,,,384.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,699.18,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,293.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",489.43,,,percent of total billed charges,,,,,,,,,,,,,,,699.18,,,percent of total billed charges,,,,,,487.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,496.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,489.43,,,percent of total billed charges,,,,,,419.51,,,percent of total billed charges,,,,,,314.63,,,percent of total billed charges,,,,,,,,,,,,,,,594.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.55,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,699.18,,,percent of total billed charges,,,,,,699.18,,,percent of total billed charges,,,,,,384.55,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,699.18,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,699.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.38,,,percent of total billed charges,,,,,,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,699.18,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,699.18,,,percent of total billed charges,,,,,,314.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.18,,,fee schedule,,,,,,699.18,,,percent of total billed charges,,,,,,699.18,,,percent of total billed charges,,,,,,699.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,699.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,594.3,,,percent of total billed charges,,,,,,524.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI STRT TI 12H 1.3 X 47,24800,CDM,0278,RC,,,,,,inpatient,facility,,,771.42,771.42,347.14,771.42,,,,,,,,,,,,,,,,,,,,655.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,578.56,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.28,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,466.32,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",547.71,,,percent of total billed charges,,,,,,,,,,,,,,,424.28,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,539.99,,,percent of total billed charges,,,,,,462.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,655.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.28,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,424.28,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,771.42,,,percent of total billed charges,,,,,,424.28,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,578.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,771.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,347.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.28,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.71,,,percent of total billed charges,,,,,,501.42,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI STRT TI 12H 1.3 X 47,24800,CDM,0278,RC,,,,,,outpatient,facility,,,771.42,771.42,129.72,771.42,,501.42,,,percent of total billed charges,,,,,,,,,,,,,,,655.71,,,percent of total billed charges,,,,,,231.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,362.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,146.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,146.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,424.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,424.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,424.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,578.57,,,percent of total billed charges,,,,,,539.99,,,percent of total billed charges,,,,,,539.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,501.42,,,percent of total billed charges,,,,,,424.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,771.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,324,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",539.99,,,percent of total billed charges,,,,,,424.28,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,771.42,,,percent of total billed charges,,,,,,538.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,547.71,,,percent of total billed charges,,,,,,,,,,,,,,,424.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,539.99,,,percent of total billed charges,,,,,,462.85,,,percent of total billed charges,,,,,,347.14,,,percent of total billed charges,,,,,,,,,,,,,,,655.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,424.28,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,771.42,,,percent of total billed charges,,,,,,771.42,,,percent of total billed charges,,,,,,424.28,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,771.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,771.42,,,percent of total billed charges,,,,,,424.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,578.56,,,percent of total billed charges,,,,,,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,771.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,771.42,,,percent of total billed charges,,,,,,347.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,424.28,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,771.42,,,fee schedule,,,,,,771.42,,,percent of total billed charges,,,,,,771.42,,,percent of total billed charges,,,,,,771.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,771.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,655.71,,,percent of total billed charges,,,,,,578.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI H EXT RT TI 8H 1.3 X 15,24801,CDM,0278,RC,,,,,,inpatient,facility,,,787.76,787.76,354.49,787.76,,,,,,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630.21,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,590.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,476.2,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",559.31,,,percent of total billed charges,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,551.43,,,percent of total billed charges,,,,,,472.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.76,,,percent of total billed charges,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,590.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,787.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,512.04,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI H EXT RT TI 8H 1.3 X 15,24801,CDM,0278,RC,,,,,,outpatient,facility,,,787.76,787.76,129.72,787.76,,512.04,,,percent of total billed charges,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,236.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,370.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,149.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,149.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,590.82,,,percent of total billed charges,,,,,,551.43,,,percent of total billed charges,,,,,,551.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,512.04,,,percent of total billed charges,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,787.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,330.86,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",551.43,,,percent of total billed charges,,,,,,433.27,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,,percent of total billed charges,,,,,,549.46,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,559.31,,,percent of total billed charges,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,551.43,,,percent of total billed charges,,,,,,472.66,,,percent of total billed charges,,,,,,354.49,,,percent of total billed charges,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,,percent of total billed charges,,,,,,787.76,,,percent of total billed charges,,,,,,433.27,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,787.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,,percent of total billed charges,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,590.82,,,percent of total billed charges,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.76,,,percent of total billed charges,,,,,,354.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,787.76,,,fee schedule,,,,,,787.76,,,percent of total billed charges,,,,,,787.76,,,percent of total billed charges,,,,,,787.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,669.6,,,percent of total billed charges,,,,,,590.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI H EXT LT TI 8H 1.3 X 15,24802,CDM,0278,RC,,,,,,inpatient,facility,,,851.4,851.4,383.13,851.4,,,,,,,,,,,,,,,,,,,,723.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,681.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,638.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,468.27,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,514.67,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",604.49,,,percent of total billed charges,,,,,,,,,,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595.98,,,percent of total billed charges,,,,,,510.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,723.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,468.27,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,468.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.4,,,percent of total billed charges,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,638.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,851.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,383.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,723.69,,,percent of total billed charges,,,,,,553.41,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI H EXT LT TI 8H 1.3 X 15,24802,CDM,0278,RC,,,,,,outpatient,facility,,,851.4,851.4,129.72,851.4,,553.41,,,percent of total billed charges,,,,,,,,,,,,,,,723.69,,,percent of total billed charges,,,,,,255.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,400.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,638.55,,,percent of total billed charges,,,,,,595.98,,,percent of total billed charges,,,,,,595.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,553.41,,,percent of total billed charges,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,851.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595.98,,,percent of total billed charges,,,,,,468.27,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,851.4,,,percent of total billed charges,,,,,,593.85,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,604.49,,,percent of total billed charges,,,,,,,,,,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595.98,,,percent of total billed charges,,,,,,510.84,,,percent of total billed charges,,,,,,383.13,,,percent of total billed charges,,,,,,,,,,,,,,,723.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,468.27,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,851.4,,,percent of total billed charges,,,,,,851.4,,,percent of total billed charges,,,,,,468.27,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,851.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,851.4,,,percent of total billed charges,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,638.55,,,percent of total billed charges,,,,,,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,851.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,851.4,,,percent of total billed charges,,,,,,383.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,638.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,468.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,851.4,,,fee schedule,,,,,,851.4,,,percent of total billed charges,,,,,,851.4,,,percent of total billed charges,,,,,,851.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,851.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,723.69,,,percent of total billed charges,,,,,,638.55,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI T TI 3H 8H 1.3 X 32,24803,CDM,0278,RC,,,,,,inpatient,facility,,,766.26,766.26,344.82,766.26,,,,,,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,613.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,574.69,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,463.2,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",544.04,,,percent of total billed charges,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,536.38,,,percent of total billed charges,,,,,,459.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.26,,,percent of total billed charges,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,574.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,766.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,344.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,498.07,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI T TI 3H 8H 1.3 X 32,24803,CDM,0278,RC,,,,,,outpatient,facility,,,766.26,766.26,129.72,766.26,,498.07,,,percent of total billed charges,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,229.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,360.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,574.7,,,percent of total billed charges,,,,,,536.38,,,percent of total billed charges,,,,,,536.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,498.07,,,percent of total billed charges,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,766.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,321.83,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",536.38,,,percent of total billed charges,,,,,,421.44,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,,percent of total billed charges,,,,,,534.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,544.04,,,percent of total billed charges,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,536.38,,,percent of total billed charges,,,,,,459.76,,,percent of total billed charges,,,,,,344.82,,,percent of total billed charges,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,,percent of total billed charges,,,,,,766.26,,,percent of total billed charges,,,,,,421.44,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,766.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,,percent of total billed charges,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,574.69,,,percent of total billed charges,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,766.26,,,percent of total billed charges,,,,,,344.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,766.26,,,fee schedule,,,,,,766.26,,,percent of total billed charges,,,,,,766.26,,,percent of total billed charges,,,,,,766.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,651.32,,,percent of total billed charges,,,,,,574.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI T TI 4H 8H 1.3 X 32,24804,CDM,0278,RC,,,,,,inpatient,facility,,,787.76,787.76,354.49,787.76,,,,,,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630.21,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,590.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,476.2,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",559.31,,,percent of total billed charges,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,551.43,,,percent of total billed charges,,,,,,472.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.76,,,percent of total billed charges,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,590.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,787.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,512.04,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI T TI 4H 8H 1.3 X 32,24804,CDM,0278,RC,,,,,,outpatient,facility,,,787.76,787.76,129.72,787.76,,512.04,,,percent of total billed charges,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,236.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,370.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,149.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,149.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,590.82,,,percent of total billed charges,,,,,,551.43,,,percent of total billed charges,,,,,,551.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,512.04,,,percent of total billed charges,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,787.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,330.86,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",551.43,,,percent of total billed charges,,,,,,433.27,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,,percent of total billed charges,,,,,,549.46,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,559.31,,,percent of total billed charges,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,551.43,,,percent of total billed charges,,,,,,472.66,,,percent of total billed charges,,,,,,354.49,,,percent of total billed charges,,,,,,,,,,,,,,,669.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,433.27,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,,percent of total billed charges,,,,,,787.76,,,percent of total billed charges,,,,,,433.27,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,787.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,,percent of total billed charges,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,590.82,,,percent of total billed charges,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,787.76,,,percent of total billed charges,,,,,,354.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,590.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,433.27,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,787.76,,,fee schedule,,,,,,787.76,,,percent of total billed charges,,,,,,787.76,,,percent of total billed charges,,,,,,787.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,787.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,669.6,,,percent of total billed charges,,,,,,590.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI Y TI 3H 8H 1.3 X 37,24805,CDM,0278,RC,,,,,,inpatient,facility,,,766.26,766.26,344.82,766.26,,,,,,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,613.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,574.69,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,463.2,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",544.04,,,percent of total billed charges,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,536.38,,,percent of total billed charges,,,,,,459.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.26,,,percent of total billed charges,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,574.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,766.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,344.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,498.07,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI Y TI 3H 8H 1.3 X 37,24805,CDM,0278,RC,,,,,,outpatient,facility,,,766.26,766.26,129.72,766.26,,498.07,,,percent of total billed charges,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,229.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,360.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,145.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,145.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,574.7,,,percent of total billed charges,,,,,,536.38,,,percent of total billed charges,,,,,,536.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,498.07,,,percent of total billed charges,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,766.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,321.83,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",536.38,,,percent of total billed charges,,,,,,421.44,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,,percent of total billed charges,,,,,,534.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,544.04,,,percent of total billed charges,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,536.38,,,percent of total billed charges,,,,,,459.76,,,percent of total billed charges,,,,,,344.82,,,percent of total billed charges,,,,,,,,,,,,,,,651.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.44,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,,percent of total billed charges,,,,,,766.26,,,percent of total billed charges,,,,,,421.44,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,766.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,,percent of total billed charges,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,574.69,,,percent of total billed charges,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,766.26,,,percent of total billed charges,,,,,,344.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,421.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,766.26,,,fee schedule,,,,,,766.26,,,percent of total billed charges,,,,,,766.26,,,percent of total billed charges,,,,,,766.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,766.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,651.32,,,percent of total billed charges,,,,,,574.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 6,24806,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 6,24806,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 7,24807,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 7,24807,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 8,24808,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 8,24808,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 9,24809,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 9,24809,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 10,24810,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 10,24810,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 11,24811,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 11,24811,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 12,24812,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 12,24812,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 14,24813,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 14,24813,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 16,24814,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 16,24814,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 18,24815,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 18,24815,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 20,24816,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 20,24816,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 22,24817,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 22,24817,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR 1.5 X 24,24818,CDM,0278,RC,,,,,,inpatient,facility,,,110.94,110.94,49.92,110.94,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,83.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,72.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR 1.5 X 24,24818,CDM,0278,RC,,,,,,outpatient,facility,,,110.94,110.94,21.08,138.8,,72.11,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,33.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.2,,,percent of total billed charges,,,,,,77.66,,,percent of total billed charges,,,,,,77.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,72.11,,,percent of total billed charges,,,,,,26.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,110.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.66,,,percent of total billed charges,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,77.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,78.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.66,,,percent of total billed charges,,,,,,66.56,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,94.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,47.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,110.94,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,,fee schedule,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,110.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,110.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,94.3,,,percent of total billed charges,,,,,,83.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI STRT TI 6H 1.5 X 29,24819,CDM,0278,RC,,,,,,inpatient,facility,,,896.12,896.12,403.25,896.12,,,,,,,,,,,,,,,,,,,,761.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,716.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,672.09,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,492.87,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,541.7,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",636.25,,,percent of total billed charges,,,,,,,,,,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,627.28,,,percent of total billed charges,,,,,,537.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,761.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.87,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,492.87,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.12,,,percent of total billed charges,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,672.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,896.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,403.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.7,,,percent of total billed charges,,,,,,582.48,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI STRT TI 6H 1.5 X 29,24819,CDM,0278,RC,,,,,,outpatient,facility,,,896.12,896.12,129.72,896.12,,582.48,,,percent of total billed charges,,,,,,,,,,,,,,,761.7,,,percent of total billed charges,,,,,,268.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,421.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,170.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,170.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,672.09,,,percent of total billed charges,,,,,,627.28,,,percent of total billed charges,,,,,,627.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,582.48,,,percent of total billed charges,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,896.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,627.28,,,percent of total billed charges,,,,,,492.87,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,896.12,,,percent of total billed charges,,,,,,625.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,636.25,,,percent of total billed charges,,,,,,,,,,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,627.28,,,percent of total billed charges,,,,,,537.67,,,percent of total billed charges,,,,,,403.25,,,percent of total billed charges,,,,,,,,,,,,,,,761.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.87,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,896.12,,,percent of total billed charges,,,,,,896.12,,,percent of total billed charges,,,,,,492.87,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,896.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,896.12,,,percent of total billed charges,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,672.09,,,percent of total billed charges,,,,,,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,896.12,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,896.12,,,percent of total billed charges,,,,,,403.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,672.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,492.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,896.12,,,fee schedule,,,,,,896.12,,,percent of total billed charges,,,,,,896.12,,,percent of total billed charges,,,,,,896.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,896.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,761.7,,,percent of total billed charges,,,,,,672.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI STRT TI 12H 1.5 X 59,24820,CDM,0278,RC,,,,,,inpatient,facility,,,761.96,761.96,342.88,761.96,,,,,,,,,,,,,,,,,,,,647.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,609.57,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,571.47,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.08,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,460.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",540.99,,,percent of total billed charges,,,,,,,,,,,,,,,419.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,533.37,,,percent of total billed charges,,,,,,457.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,647.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.08,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,419.08,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.96,,,percent of total billed charges,,,,,,419.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,571.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,761.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,342.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.67,,,percent of total billed charges,,,,,,495.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI STRT TI 12H 1.5 X 59,24820,CDM,0278,RC,,,,,,outpatient,facility,,,761.96,761.96,129.72,761.96,,495.27,,,percent of total billed charges,,,,,,,,,,,,,,,647.67,,,percent of total billed charges,,,,,,228.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,358.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,144.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,144.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,419.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,419.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,419.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,571.47,,,percent of total billed charges,,,,,,533.37,,,percent of total billed charges,,,,,,533.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,495.27,,,percent of total billed charges,,,,,,419.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,761.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,320.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",533.37,,,percent of total billed charges,,,,,,419.08,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,761.96,,,percent of total billed charges,,,,,,531.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,540.99,,,percent of total billed charges,,,,,,,,,,,,,,,419.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,533.37,,,percent of total billed charges,,,,,,457.18,,,percent of total billed charges,,,,,,342.88,,,percent of total billed charges,,,,,,,,,,,,,,,647.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.08,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,761.96,,,percent of total billed charges,,,,,,761.96,,,percent of total billed charges,,,,,,419.08,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,761.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,761.96,,,percent of total billed charges,,,,,,419.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,571.47,,,percent of total billed charges,,,,,,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,761.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,761.96,,,percent of total billed charges,,,,,,342.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,419.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,761.96,,,fee schedule,,,,,,761.96,,,percent of total billed charges,,,,,,761.96,,,percent of total billed charges,,,,,,761.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,761.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,647.67,,,percent of total billed charges,,,,,,571.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI T TI 3H 8H 1.5 X 44,24821,CDM,0278,RC,,,,,,inpatient,facility,,,878.92,878.92,395.51,878.92,,,,,,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,703.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,659.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,483.41,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,531.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",624.03,,,percent of total billed charges,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,615.24,,,percent of total billed charges,,,,,,527.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.92,,,percent of total billed charges,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,659.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,878.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,395.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,571.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI T TI 3H 8H 1.5 X 44,24821,CDM,0278,RC,,,,,,outpatient,facility,,,878.92,878.92,129.72,878.92,,571.3,,,percent of total billed charges,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,263.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,413.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,659.19,,,percent of total billed charges,,,,,,615.24,,,percent of total billed charges,,,,,,615.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,571.3,,,percent of total billed charges,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,878.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,615.24,,,percent of total billed charges,,,,,,483.41,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,,percent of total billed charges,,,,,,613.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,624.03,,,percent of total billed charges,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,615.24,,,percent of total billed charges,,,,,,527.35,,,percent of total billed charges,,,,,,395.51,,,percent of total billed charges,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,,percent of total billed charges,,,,,,878.92,,,percent of total billed charges,,,,,,483.41,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,878.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,,percent of total billed charges,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,659.19,,,percent of total billed charges,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,878.92,,,percent of total billed charges,,,,,,395.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,659.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,878.92,,,fee schedule,,,,,,878.92,,,percent of total billed charges,,,,,,878.92,,,percent of total billed charges,,,,,,878.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,747.08,,,percent of total billed charges,,,,,,659.19,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI T TI 4H 8H 1.5 X 44,24822,CDM,0278,RC,,,,,,inpatient,facility,,,878.92,878.92,395.51,878.92,,,,,,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,703.14,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,659.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,483.41,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,531.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",624.03,,,percent of total billed charges,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,615.24,,,percent of total billed charges,,,,,,527.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.92,,,percent of total billed charges,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,659.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,878.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,395.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,571.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI T TI 4H 8H 1.5 X 44,24822,CDM,0278,RC,,,,,,outpatient,facility,,,878.92,878.92,129.72,878.92,,571.3,,,percent of total billed charges,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,263.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,413.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,166.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,166.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,659.19,,,percent of total billed charges,,,,,,615.24,,,percent of total billed charges,,,,,,615.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,571.3,,,percent of total billed charges,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,878.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,615.24,,,percent of total billed charges,,,,,,483.41,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,,percent of total billed charges,,,,,,613.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,624.03,,,percent of total billed charges,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,615.24,,,percent of total billed charges,,,,,,527.35,,,percent of total billed charges,,,,,,395.51,,,percent of total billed charges,,,,,,,,,,,,,,,747.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.41,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,,percent of total billed charges,,,,,,878.92,,,percent of total billed charges,,,,,,483.41,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,878.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,,percent of total billed charges,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,659.19,,,percent of total billed charges,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,878.92,,,percent of total billed charges,,,,,,395.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,659.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,483.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,878.92,,,fee schedule,,,,,,878.92,,,percent of total billed charges,,,,,,878.92,,,percent of total billed charges,,,,,,878.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,878.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,747.08,,,percent of total billed charges,,,,,,659.19,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI H EXT LT TI 8H 1.5 X 22,24823,CDM,0278,RC,,,,,,inpatient,facility,,,847.1,847.1,381.19,847.1,,,,,,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,677.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,635.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,465.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,512.07,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",601.44,,,percent of total billed charges,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,592.97,,,percent of total billed charges,,,,,,508.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.1,,,percent of total billed charges,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,635.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,847.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,381.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,550.62,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI H EXT LT TI 8H 1.5 X 22,24823,CDM,0278,RC,,,,,,outpatient,facility,,,847.1,847.1,129.72,847.1,,550.62,,,percent of total billed charges,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,254.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,398.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,160.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,160.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,635.32,,,percent of total billed charges,,,,,,592.97,,,percent of total billed charges,,,,,,592.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,550.62,,,percent of total billed charges,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,847.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,592.97,,,percent of total billed charges,,,,,,465.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,,percent of total billed charges,,,,,,590.85,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,601.44,,,percent of total billed charges,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,592.97,,,percent of total billed charges,,,,,,508.26,,,percent of total billed charges,,,,,,381.19,,,percent of total billed charges,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,,percent of total billed charges,,,,,,847.1,,,percent of total billed charges,,,,,,465.91,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,847.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,,percent of total billed charges,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,635.33,,,percent of total billed charges,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,847.1,,,percent of total billed charges,,,,,,381.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,847.1,,,fee schedule,,,,,,847.1,,,percent of total billed charges,,,,,,847.1,,,percent of total billed charges,,,,,,847.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,720.04,,,percent of total billed charges,,,,,,635.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI H EXT RT TI 8H 1.5 X 22,24824,CDM,0278,RC,,,,,,inpatient,facility,,,847.1,847.1,381.19,847.1,,,,,,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,677.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,635.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,465.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,512.07,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",601.44,,,percent of total billed charges,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,592.97,,,percent of total billed charges,,,,,,508.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.1,,,percent of total billed charges,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,635.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,847.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,381.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,550.62,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI H EXT RT TI 8H 1.5 X 22,24824,CDM,0278,RC,,,,,,outpatient,facility,,,847.1,847.1,129.72,847.1,,550.62,,,percent of total billed charges,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,254.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,398.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,160.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,160.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,635.32,,,percent of total billed charges,,,,,,592.97,,,percent of total billed charges,,,,,,592.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,550.62,,,percent of total billed charges,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,847.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,592.97,,,percent of total billed charges,,,,,,465.91,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,,percent of total billed charges,,,,,,590.85,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,601.44,,,percent of total billed charges,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,592.97,,,percent of total billed charges,,,,,,508.26,,,percent of total billed charges,,,,,,381.19,,,percent of total billed charges,,,,,,,,,,,,,,,720.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.91,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,,percent of total billed charges,,,,,,847.1,,,percent of total billed charges,,,,,,465.91,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,847.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,,percent of total billed charges,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,635.33,,,percent of total billed charges,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,847.1,,,percent of total billed charges,,,,,,381.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,465.91,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,847.1,,,fee schedule,,,,,,847.1,,,percent of total billed charges,,,,,,847.1,,,percent of total billed charges,,,,,,847.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,847.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,720.04,,,percent of total billed charges,,,,,,635.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI Y TI 3H 8H 1.5 X 46,24825,CDM,0278,RC,,,,,,inpatient,facility,,,845.38,845.38,380.42,845.38,,,,,,,,,,,,,,,,,,,,718.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,676.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,634.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,464.96,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,511.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",600.22,,,percent of total billed charges,,,,,,,,,,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,591.77,,,percent of total billed charges,,,,,,507.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,718.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.96,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,464.96,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,845.38,,,percent of total billed charges,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,634.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,845.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,380.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,718.57,,,percent of total billed charges,,,,,,549.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI Y TI 3H 8H 1.5 X 46,24825,CDM,0278,RC,,,,,,outpatient,facility,,,845.38,845.38,129.72,845.38,,549.5,,,percent of total billed charges,,,,,,,,,,,,,,,718.57,,,percent of total billed charges,,,,,,253.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,397.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,160.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,160.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,634.03,,,percent of total billed charges,,,,,,591.77,,,percent of total billed charges,,,,,,591.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,549.5,,,percent of total billed charges,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,845.38,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,591.77,,,percent of total billed charges,,,,,,464.96,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,845.38,,,percent of total billed charges,,,,,,589.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,600.22,,,percent of total billed charges,,,,,,,,,,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,591.77,,,percent of total billed charges,,,,,,507.23,,,percent of total billed charges,,,,,,380.42,,,percent of total billed charges,,,,,,,,,,,,,,,718.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,464.96,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,845.38,,,percent of total billed charges,,,,,,845.38,,,percent of total billed charges,,,,,,464.96,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,845.38,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,845.38,,,percent of total billed charges,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,634.04,,,percent of total billed charges,,,,,,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,845.38,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,845.38,,,percent of total billed charges,,,,,,380.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,634.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,464.96,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,845.38,,,fee schedule,,,,,,845.38,,,percent of total billed charges,,,,,,845.38,,,percent of total billed charges,,,,,,845.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,845.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,718.57,,,percent of total billed charges,,,,,,634.03,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR LT TI F MHS 7H 1.5 X 36,24826,CDM,0278,RC,,,,,,inpatient,facility,,,1050.92,1050.92,472.91,1050.92,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,840.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,788.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,578.01,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,635.28,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",746.15,,,percent of total billed charges,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,735.64,,,percent of total billed charges,,,,,,630.55,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1050.92,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,788.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1050.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,472.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,683.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR LT TI F MHS 7H 1.5 X 36,24826,CDM,0278,RC,,,,,,outpatient,facility,,,1050.92,1050.92,129.72,1050.92,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,315.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,199.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,199.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,788.19,,,percent of total billed charges,,,,,,735.64,,,percent of total billed charges,,,,,,735.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,683.1,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1050.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,735.64,,,percent of total billed charges,,,,,,578.01,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,,percent of total billed charges,,,,,,733.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,746.15,,,percent of total billed charges,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,735.64,,,percent of total billed charges,,,,,,630.55,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,,percent of total billed charges,,,,,,1050.92,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1050.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,788.19,,,percent of total billed charges,,,,,,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050.92,,,percent of total billed charges,,,,,,472.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,788.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1050.92,,,fee schedule,,,,,,1050.92,,,percent of total billed charges,,,,,,1050.92,,,percent of total billed charges,,,,,,1050.92,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,893.28,,,percent of total billed charges,,,,,,788.19,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR RT TI F MHS 7H 1.5 X 36,24827,CDM,0278,RC,,,,,,inpatient,facility,,,1050.92,1050.92,472.91,1050.92,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,840.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,788.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,578.01,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,635.28,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",746.15,,,percent of total billed charges,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,735.64,,,percent of total billed charges,,,,,,630.55,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1050.92,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,788.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1050.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,472.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,683.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR RT TI F MHS 7H 1.5 X 36,24827,CDM,0278,RC,,,,,,outpatient,facility,,,1050.92,1050.92,129.72,1050.92,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,315.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,199.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,199.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,788.19,,,percent of total billed charges,,,,,,735.64,,,percent of total billed charges,,,,,,735.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,683.1,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1050.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,735.64,,,percent of total billed charges,,,,,,578.01,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,,percent of total billed charges,,,,,,733.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,746.15,,,percent of total billed charges,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,735.64,,,percent of total billed charges,,,,,,630.55,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,893.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,578.01,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,,percent of total billed charges,,,,,,1050.92,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1050.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,788.19,,,percent of total billed charges,,,,,,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050.92,,,percent of total billed charges,,,,,,472.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,788.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1050.92,,,fee schedule,,,,,,1050.92,,,percent of total billed charges,,,,,,1050.92,,,percent of total billed charges,,,,,,1050.92,,,percent of total billed charges,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,578.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1050.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,893.28,,,percent of total billed charges,,,,,,788.19,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI 1.1 X 55,24828,CDM,0272,RC,,,,,,inpatient,facility,,,261.87,261.87,117.84,261.87,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI 1.1 X 55,24828,CDM,0272,RC,,,,,,outpatient,facility,,,261.87,261.87,49.76,1016,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,78.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,123.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,196.4,,,percent of total billed charges,,,,,,183.31,,,percent of total billed charges,,,,,,183.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,62.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",176.76,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,109.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",183.31,,,percent of total billed charges,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,182.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,112.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,fee schedule,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,125.7,,,percent of total billed charges,,,,,,,,,,,,,,,154.5,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,222.59,,,percent of total billed charges,,,,,,196.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI 1.5 X 65,24829,CDM,0272,RC,,,,,,inpatient,facility,,,261.87,261.87,117.84,261.87,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI 1.5 X 65,24829,CDM,0272,RC,,,,,,outpatient,facility,,,261.87,261.87,49.76,1016,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,78.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,123.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,196.4,,,percent of total billed charges,,,,,,183.31,,,percent of total billed charges,,,,,,183.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,62.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",176.76,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,109.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",183.31,,,percent of total billed charges,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,182.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,112.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,fee schedule,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,125.7,,,percent of total billed charges,,,,,,,,,,,,,,,154.5,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,222.59,,,percent of total billed charges,,,,,,196.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 6,24830,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 6,24830,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 7,24831,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 7,24831,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 8,24832,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 8,24832,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 9,24833,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 9,24833,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 10,24834,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 10,24834,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 11,24835,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 11,24835,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 12,24836,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 12,24836,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 13,24837,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 13,24837,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 14,24838,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 14,24838,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 16,24839,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 16,24839,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 18,24840,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 18,24840,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 20,24841,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 20,24841,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 22,24842,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 22,24842,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 24,24843,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 24,24843,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 26,24844,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 26,24844,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 28,24845,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 28,24845,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 30,24846,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 30,24846,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 32,24847,CDM,0278,RC,,,,,,inpatient,facility,,,87.72,87.72,39.47,87.72,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,65.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.03,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,57.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.0 X 32,24847,CDM,0278,RC,,,,,,outpatient,facility,,,87.72,87.72,16.67,138.8,,57.02,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,26.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,65.79,,,percent of total billed charges,,,,,,61.4,,,percent of total billed charges,,,,,,61.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.02,,,percent of total billed charges,,,,,,21.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.4,,,percent of total billed charges,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,61.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.4,,,percent of total billed charges,,,,,,52.63,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,74.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,37.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.72,,,percent of total billed charges,,,,,,39.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,,fee schedule,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,87.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.56,,,percent of total billed charges,,,,,,65.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR LT TI F MHS 7H 2.0 X 39,24848,CDM,0278,RC,,,,,,inpatient,facility,,,1560.9,1560.9,702.41,1560.9,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1326.76,,,percent of total billed charges,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1248.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1170.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,858.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,943.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1108.24,,,percent of total billed charges,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1092.63,,,percent of total billed charges,,,,,,936.54,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1326.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.9,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1170.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1560.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,702.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1326.76,,,percent of total billed charges,,,,,,1014.59,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR LT TI F MHS 7H 2.0 X 39,24848,CDM,0278,RC,,,,,,outpatient,facility,,,1560.9,1560.9,129.72,1560.9,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1326.76,,,percent of total billed charges,,,,,,468.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,296.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,296.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1170.68,,,percent of total billed charges,,,,,,1092.63,,,percent of total billed charges,,,,,,1092.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1014.59,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1560.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1092.63,,,percent of total billed charges,,,,,,858.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,,percent of total billed charges,,,,,,1088.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1108.24,,,percent of total billed charges,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1092.63,,,percent of total billed charges,,,,,,936.54,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1326.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,,percent of total billed charges,,,,,,1560.9,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1170.68,,,percent of total billed charges,,,,,,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1560.9,,,percent of total billed charges,,,,,,702.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1170.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1560.9,,,fee schedule,,,,,,1560.9,,,percent of total billed charges,,,,,,1560.9,,,percent of total billed charges,,,,,,1560.9,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1326.76,,,percent of total billed charges,,,,,,1170.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR RT TI F MHS 7H 2.0 X 39,24849,CDM,0278,RC,,,,,,inpatient,facility,,,1560.9,1560.9,702.41,1560.9,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1326.76,,,percent of total billed charges,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1248.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1170.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,858.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,943.56,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1108.24,,,percent of total billed charges,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1092.63,,,percent of total billed charges,,,,,,936.54,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1326.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.9,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1170.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1560.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,702.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1326.76,,,percent of total billed charges,,,,,,1014.59,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR RT TI F MHS 7H 2.0 X 39,24849,CDM,0278,RC,,,,,,outpatient,facility,,,1560.9,1560.9,129.72,1560.9,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1326.76,,,percent of total billed charges,,,,,,468.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,296.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,296.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1170.68,,,percent of total billed charges,,,,,,1092.63,,,percent of total billed charges,,,,,,1092.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1014.59,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1560.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1092.63,,,percent of total billed charges,,,,,,858.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,,percent of total billed charges,,,,,,1088.73,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1108.24,,,percent of total billed charges,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1092.63,,,percent of total billed charges,,,,,,936.54,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1326.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,858.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,,percent of total billed charges,,,,,,1560.9,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1170.68,,,percent of total billed charges,,,,,,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1560.9,,,percent of total billed charges,,,,,,702.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1170.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1560.9,,,fee schedule,,,,,,1560.9,,,percent of total billed charges,,,,,,1560.9,,,percent of total billed charges,,,,,,1560.9,,,percent of total billed charges,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,858.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1560.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1326.76,,,percent of total billed charges,,,,,,1170.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI STRT TI 6H 2.0 X 35,24850,CDM,0278,RC,,,,,,inpatient,facility,,,915.9,915.9,412.15,915.9,,,,,,,,,,,,,,,,,,,,778.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,686.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,503.74,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,553.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",650.29,,,percent of total billed charges,,,,,,,,,,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,641.13,,,percent of total billed charges,,,,,,549.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,778.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.74,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,503.74,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,915.9,,,percent of total billed charges,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,686.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,915.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,412.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.52,,,percent of total billed charges,,,,,,595.34,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI STRT TI 6H 2.0 X 35,24850,CDM,0278,RC,,,,,,outpatient,facility,,,915.9,915.9,129.72,915.9,,595.34,,,percent of total billed charges,,,,,,,,,,,,,,,778.52,,,percent of total billed charges,,,,,,274.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,430.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,174.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,174.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,686.92,,,percent of total billed charges,,,,,,641.13,,,percent of total billed charges,,,,,,641.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,595.34,,,percent of total billed charges,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,915.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,641.13,,,percent of total billed charges,,,,,,503.74,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,915.9,,,percent of total billed charges,,,,,,638.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,650.29,,,percent of total billed charges,,,,,,,,,,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,641.13,,,percent of total billed charges,,,,,,549.54,,,percent of total billed charges,,,,,,412.15,,,percent of total billed charges,,,,,,,,,,,,,,,778.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.74,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,915.9,,,percent of total billed charges,,,,,,915.9,,,percent of total billed charges,,,,,,503.74,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,915.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,915.9,,,percent of total billed charges,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,686.92,,,percent of total billed charges,,,,,,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,915.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,915.9,,,percent of total billed charges,,,,,,412.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,686.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,503.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,915.9,,,fee schedule,,,,,,915.9,,,percent of total billed charges,,,,,,915.9,,,percent of total billed charges,,,,,,915.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,915.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,778.52,,,percent of total billed charges,,,,,,686.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI STRT TI 12H 2.0 X 71,24851,CDM,0278,RC,,,,,,inpatient,facility,,,754.22,754.22,339.4,754.22,,,,,,,,,,,,,,,,,,,,641.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,603.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,565.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.82,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,455.93,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",535.5,,,percent of total billed charges,,,,,,,,,,,,,,,414.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,527.95,,,percent of total billed charges,,,,,,452.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,641.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.82,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,414.82,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.22,,,percent of total billed charges,,,,,,414.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,565.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,754.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,339.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.09,,,percent of total billed charges,,,,,,490.24,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI STRT TI 12H 2.0 X 71,24851,CDM,0278,RC,,,,,,outpatient,facility,,,754.22,754.22,129.72,754.22,,490.24,,,percent of total billed charges,,,,,,,,,,,,,,,641.09,,,percent of total billed charges,,,,,,226.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,354.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,143.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,143.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,414.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,414.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,414.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,565.67,,,percent of total billed charges,,,,,,527.95,,,percent of total billed charges,,,,,,527.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,490.24,,,percent of total billed charges,,,,,,414.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,754.22,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,316.77,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",527.95,,,percent of total billed charges,,,,,,414.82,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,754.22,,,percent of total billed charges,,,,,,526.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,535.5,,,percent of total billed charges,,,,,,,,,,,,,,,414.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,527.95,,,percent of total billed charges,,,,,,452.53,,,percent of total billed charges,,,,,,339.4,,,percent of total billed charges,,,,,,,,,,,,,,,641.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.82,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,754.22,,,percent of total billed charges,,,,,,754.22,,,percent of total billed charges,,,,,,414.82,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,754.22,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,754.22,,,percent of total billed charges,,,,,,414.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,565.66,,,percent of total billed charges,,,,,,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,754.22,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,754.22,,,percent of total billed charges,,,,,,339.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,414.82,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,754.22,,,fee schedule,,,,,,754.22,,,percent of total billed charges,,,,,,754.22,,,percent of total billed charges,,,,,,754.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,754.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,641.09,,,percent of total billed charges,,,,,,565.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI T TI 2H 8H 2.0 X 53,24852,CDM,0278,RC,,,,,,inpatient,facility,,,790.34,790.34,355.65,790.34,,,,,,,,,,,,,,,,,,,,671.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.27,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,592.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.69,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,477.76,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",561.14,,,percent of total billed charges,,,,,,,,,,,,,,,434.69,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,553.24,,,percent of total billed charges,,,,,,474.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,671.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.69,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,434.69,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.34,,,percent of total billed charges,,,,,,434.69,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,592.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,790.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,355.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.69,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671.79,,,percent of total billed charges,,,,,,513.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI T TI 2H 8H 2.0 X 53,24852,CDM,0278,RC,,,,,,outpatient,facility,,,790.34,790.34,129.72,790.34,,513.72,,,percent of total billed charges,,,,,,,,,,,,,,,671.79,,,percent of total billed charges,,,,,,237.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,371.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.69,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,150.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,150.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,434.69,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,434.69,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,434.69,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,592.76,,,percent of total billed charges,,,,,,553.24,,,percent of total billed charges,,,,,,553.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,513.72,,,percent of total billed charges,,,,,,434.69,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,790.34,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,331.94,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",553.24,,,percent of total billed charges,,,,,,434.69,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,790.34,,,percent of total billed charges,,,,,,551.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,561.14,,,percent of total billed charges,,,,,,,,,,,,,,,434.69,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,553.24,,,percent of total billed charges,,,,,,474.2,,,percent of total billed charges,,,,,,355.65,,,percent of total billed charges,,,,,,,,,,,,,,,671.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,434.69,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,790.34,,,percent of total billed charges,,,,,,790.34,,,percent of total billed charges,,,,,,434.69,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,790.34,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,790.34,,,percent of total billed charges,,,,,,434.69,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,592.76,,,percent of total billed charges,,,,,,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,790.34,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,790.34,,,percent of total billed charges,,,,,,355.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,434.69,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,790.34,,,fee schedule,,,,,,790.34,,,percent of total billed charges,,,,,,790.34,,,percent of total billed charges,,,,,,790.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,790.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,671.79,,,percent of total billed charges,,,,,,592.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI T TI 3H 8H 2.0 X 53,24853,CDM,0278,RC,,,,,,inpatient,facility,,,802.38,802.38,361.07,802.38,,,,,,,,,,,,,,,,,,,,682.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,601.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,441.31,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,485.04,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",569.69,,,percent of total billed charges,,,,,,,,,,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,561.67,,,percent of total billed charges,,,,,,481.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,682.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.31,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,441.31,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,802.38,,,percent of total billed charges,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,601.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,802.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,361.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.02,,,percent of total billed charges,,,,,,521.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI T TI 3H 8H 2.0 X 53,24853,CDM,0278,RC,,,,,,outpatient,facility,,,802.38,802.38,129.72,802.38,,521.55,,,percent of total billed charges,,,,,,,,,,,,,,,682.02,,,percent of total billed charges,,,,,,240.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,377.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,152.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,152.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,601.79,,,percent of total billed charges,,,,,,561.67,,,percent of total billed charges,,,,,,561.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,521.55,,,percent of total billed charges,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,802.38,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,561.67,,,percent of total billed charges,,,,,,441.31,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,802.38,,,percent of total billed charges,,,,,,559.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,569.69,,,percent of total billed charges,,,,,,,,,,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,561.67,,,percent of total billed charges,,,,,,481.43,,,percent of total billed charges,,,,,,361.07,,,percent of total billed charges,,,,,,,,,,,,,,,682.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.31,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,802.38,,,percent of total billed charges,,,,,,802.38,,,percent of total billed charges,,,,,,441.31,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,802.38,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,802.38,,,percent of total billed charges,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,601.78,,,percent of total billed charges,,,,,,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,802.38,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,802.38,,,percent of total billed charges,,,,,,361.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,441.31,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,802.38,,,fee schedule,,,,,,802.38,,,percent of total billed charges,,,,,,802.38,,,percent of total billed charges,,,,,,802.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,802.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,682.02,,,percent of total billed charges,,,,,,601.78,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI Y TI 3H 8H 2.0 X 55,24854,CDM,0278,RC,,,,,,inpatient,facility,,,1093.06,1093.06,491.88,1093.06,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,929.1,,,percent of total billed charges,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,874.45,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,819.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,601.18,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,660.75,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",776.07,,,percent of total billed charges,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,765.14,,,percent of total billed charges,,,,,,655.84,,,percent of total billed charges,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,929.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.18,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.06,,,percent of total billed charges,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,819.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1093.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,491.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,929.1,,,percent of total billed charges,,,,,,710.49,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI Y TI 3H 8H 2.0 X 55,24854,CDM,0278,RC,,,,,,outpatient,facility,,,1093.06,1093.06,129.72,1093.06,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,929.1,,,percent of total billed charges,,,,,,327.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,207.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,207.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,819.8,,,percent of total billed charges,,,,,,765.14,,,percent of total billed charges,,,,,,765.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,710.49,,,percent of total billed charges,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1093.06,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,765.14,,,percent of total billed charges,,,,,,601.18,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1093.06,,,percent of total billed charges,,,,,,762.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,776.07,,,percent of total billed charges,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,765.14,,,percent of total billed charges,,,,,,655.84,,,percent of total billed charges,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,929.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.18,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1093.06,,,percent of total billed charges,,,,,,1093.06,,,percent of total billed charges,,,,,,601.18,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.06,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1093.06,,,percent of total billed charges,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,819.8,,,percent of total billed charges,,,,,,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1093.06,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1093.06,,,percent of total billed charges,,,,,,491.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,819.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1093.06,,,fee schedule,,,,,,1093.06,,,percent of total billed charges,,,,,,1093.06,,,percent of total billed charges,,,,,,1093.06,,,percent of total billed charges,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,601.18,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1093.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,929.1,,,percent of total billed charges,,,,,,819.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI LC DCP TI 4H 2.0 X 24,24855,CDM,0278,RC,,,,,,inpatient,facility,,,698.32,698.32,314.24,698.32,,,,,,,,,,,,,,,,,,,,593.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,558.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,523.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.13,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",495.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,488.82,,,percent of total billed charges,,,,,,418.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,593.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.08,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,384.08,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,698.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,698.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,314.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,593.57,,,percent of total billed charges,,,,,,453.91,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI LC DCP TI 4H 2.0 X 24,24855,CDM,0278,RC,,,,,,outpatient,facility,,,698.32,698.32,129.72,698.32,,453.91,,,percent of total billed charges,,,,,,,,,,,,,,,593.57,,,percent of total billed charges,,,,,,209.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,328.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,132.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,384.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,384.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,384.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,523.74,,,percent of total billed charges,,,,,,488.82,,,percent of total billed charges,,,,,,488.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,453.91,,,percent of total billed charges,,,,,,384.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,698.32,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,293.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",488.82,,,percent of total billed charges,,,,,,,,,,,,,,,698.32,,,percent of total billed charges,,,,,,487.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,495.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,488.82,,,percent of total billed charges,,,,,,418.99,,,percent of total billed charges,,,,,,314.24,,,percent of total billed charges,,,,,,,,,,,,,,,593.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.08,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,698.32,,,percent of total billed charges,,,,,,698.32,,,percent of total billed charges,,,,,,384.08,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,698.32,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,698.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.74,,,percent of total billed charges,,,,,,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,698.32,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,698.32,,,percent of total billed charges,,,,,,314.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,698.32,,,fee schedule,,,,,,698.32,,,percent of total billed charges,,,,,,698.32,,,percent of total billed charges,,,,,,698.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,698.32,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,593.57,,,percent of total billed charges,,,,,,523.74,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI LC DCP TI 6H 2.0 X 36,24856,CDM,0278,RC,,,,,,inpatient,facility,,,823.02,823.02,370.36,823.02,,,,,,,,,,,,,,,,,,,,699.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,658.42,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,617.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,452.66,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,497.52,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",584.34,,,percent of total billed charges,,,,,,,,,,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,576.11,,,percent of total billed charges,,,,,,493.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,699.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.66,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,452.66,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,823.02,,,percent of total billed charges,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,617.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,823.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,370.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.57,,,percent of total billed charges,,,,,,534.96,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI LC DCP TI 6H 2.0 X 36,24856,CDM,0278,RC,,,,,,outpatient,facility,,,823.02,823.02,129.72,823.02,,534.96,,,percent of total billed charges,,,,,,,,,,,,,,,699.57,,,percent of total billed charges,,,,,,246.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,386.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,156.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,156.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,617.27,,,percent of total billed charges,,,,,,576.11,,,percent of total billed charges,,,,,,576.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,534.96,,,percent of total billed charges,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,823.02,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,576.11,,,percent of total billed charges,,,,,,452.66,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,823.02,,,percent of total billed charges,,,,,,574.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,584.34,,,percent of total billed charges,,,,,,,,,,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,576.11,,,percent of total billed charges,,,,,,493.81,,,percent of total billed charges,,,,,,370.36,,,percent of total billed charges,,,,,,,,,,,,,,,699.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.66,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,823.02,,,percent of total billed charges,,,,,,823.02,,,percent of total billed charges,,,,,,452.66,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,823.02,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,823.02,,,percent of total billed charges,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,617.26,,,percent of total billed charges,,,,,,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,823.02,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,823.02,,,percent of total billed charges,,,,,,370.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,452.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,823.02,,,fee schedule,,,,,,823.02,,,percent of total billed charges,,,,,,823.02,,,percent of total billed charges,,,,,,823.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,823.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,699.57,,,percent of total billed charges,,,,,,617.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI LC DCP TI 8H 2.0 X 48,24857,CDM,0278,RC,,,,,,inpatient,facility,,,932.24,932.24,419.51,932.24,,,,,,,,,,,,,,,,,,,,792.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,745.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,699.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,512.73,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,563.54,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",661.89,,,percent of total billed charges,,,,,,,,,,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,652.57,,,percent of total billed charges,,,,,,559.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,792.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.73,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,512.73,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,932.24,,,percent of total billed charges,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,699.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,932.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,419.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,792.4,,,percent of total billed charges,,,,,,605.96,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI LC DCP TI 8H 2.0 X 48,24857,CDM,0278,RC,,,,,,outpatient,facility,,,932.24,932.24,129.72,932.24,,605.96,,,percent of total billed charges,,,,,,,,,,,,,,,792.4,,,percent of total billed charges,,,,,,279.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,438.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,177.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,699.18,,,percent of total billed charges,,,,,,652.57,,,percent of total billed charges,,,,,,652.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,605.96,,,percent of total billed charges,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,932.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,652.57,,,percent of total billed charges,,,,,,512.73,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,932.24,,,percent of total billed charges,,,,,,650.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,661.89,,,percent of total billed charges,,,,,,,,,,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,652.57,,,percent of total billed charges,,,,,,559.34,,,percent of total billed charges,,,,,,419.51,,,percent of total billed charges,,,,,,,,,,,,,,,792.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,512.73,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,932.24,,,percent of total billed charges,,,,,,932.24,,,percent of total billed charges,,,,,,512.73,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,932.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,932.24,,,percent of total billed charges,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,699.18,,,percent of total billed charges,,,,,,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,932.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,932.24,,,percent of total billed charges,,,,,,419.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,699.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,512.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,932.24,,,fee schedule,,,,,,932.24,,,percent of total billed charges,,,,,,932.24,,,percent of total billed charges,,,,,,932.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,932.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,792.4,,,percent of total billed charges,,,,,,699.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC MINI 2.0 X 65,24858,CDM,0272,RC,,,,,,inpatient,facility,,,261.87,261.87,117.84,261.87,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC MINI 2.0 X 65,24858,CDM,0272,RC,,,,,,outpatient,facility,,,261.87,261.87,49.76,1016,,170.22,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,78.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,123.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,49.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,196.4,,,percent of total billed charges,,,,,,183.31,,,percent of total billed charges,,,,,,183.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,170.22,,,percent of total billed charges,,,,,,62.85,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",176.76,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,109.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",183.31,,,percent of total billed charges,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,182.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,185.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,183.31,,,percent of total billed charges,,,,,,157.12,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,222.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,112.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,261.87,,,percent of total billed charges,,,,,,117.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.87,,,fee schedule,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,261.87,,,percent of total billed charges,,,,,,125.7,,,percent of total billed charges,,,,,,,,,,,,,,,154.5,,,percent of total billed charges,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,261.87,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,222.59,,,percent of total billed charges,,,,,,196.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 6,24859,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 6,24859,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 7,24860,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 7,24860,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 8,24861,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 8,24861,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 9,24862,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 9,24862,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 10,24863,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 10,24863,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 11,24864,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 11,24864,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 12,24865,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 12,24865,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 13,24866,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 13,24866,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 14,24867,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 14,24867,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 16,24868,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 16,24868,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 18,24869,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 18,24869,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 20,24870,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 20,24870,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 22,24871,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 22,24871,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 24,24872,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 24,24872,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 26,24873,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 26,24873,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 28,24874,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 28,24874,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 30,24875,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 30,24875,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 32,24876,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 32,24876,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 34,24877,CDM,0278,RC,,,,,,inpatient,facility,,,177.16,177.16,79.72,177.16,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,132.87,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.09,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,115.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST CR F MHS 2.4 X 34,24877,CDM,0278,RC,,,,,,outpatient,facility,,,177.16,177.16,33.66,177.16,,115.15,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,53.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.44,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.87,,,percent of total billed charges,,,,,,124.01,,,percent of total billed charges,,,,,,124.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.15,,,percent of total billed charges,,,,,,42.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.01,,,percent of total billed charges,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,123.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,125.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.01,,,percent of total billed charges,,,,,,106.3,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,150.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,76.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.16,,,percent of total billed charges,,,,,,79.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,,fee schedule,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,177.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.59,,,percent of total billed charges,,,,,,132.87,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN SYN BUTTR TI F MHS 1.8 X 18,24878,CDM,0278,RC,,,,,,inpatient,facility,,,132.44,132.44,59.6,132.44,,,,,,,,,,,,,,,,,,,,112.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.95,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,99.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",94.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.71,,,percent of total billed charges,,,,,,79.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,112.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,132.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.57,,,percent of total billed charges,,,,,,86.09,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN SYN BUTTR TI F MHS 1.8 X 18,24878,CDM,0278,RC,,,,,,outpatient,facility,,,132.44,132.44,25.16,138.8,,86.09,,,percent of total billed charges,,,,,,,,,,,,,,,112.57,,,percent of total billed charges,,,,,,39.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,25.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,72.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,72.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,72.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.33,,,percent of total billed charges,,,,,,92.71,,,percent of total billed charges,,,,,,92.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.09,,,percent of total billed charges,,,,,,31.79,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,132.44,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.62,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",92.71,,,percent of total billed charges,,,,,,,,,,,,,,,132.44,,,percent of total billed charges,,,,,,92.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.71,,,percent of total billed charges,,,,,,79.46,,,percent of total billed charges,,,,,,59.6,,,percent of total billed charges,,,,,,,,,,,,,,,112.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.44,,,percent of total billed charges,,,,,,132.44,,,percent of total billed charges,,,,,,56.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,132.44,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,132.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.33,,,percent of total billed charges,,,,,,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.44,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,132.44,,,percent of total billed charges,,,,,,59.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.44,,,fee schedule,,,,,,132.44,,,percent of total billed charges,,,,,,132.44,,,percent of total billed charges,,,,,,132.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,132.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,112.57,,,percent of total billed charges,,,,,,99.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI STRT TI 6H 2.4 X 36,24879,CDM,0278,RC,,,,,,inpatient,facility,,,832.48,832.48,374.62,832.48,,,,,,,,,,,,,,,,,,,,707.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,665.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,624.36,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,457.86,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,503.23,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",591.06,,,percent of total billed charges,,,,,,,,,,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,582.74,,,percent of total billed charges,,,,,,499.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,707.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.86,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,457.86,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.48,,,percent of total billed charges,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,624.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,832.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,374.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,707.61,,,percent of total billed charges,,,,,,541.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI STRT TI 6H 2.4 X 36,24879,CDM,0278,RC,,,,,,outpatient,facility,,,832.48,832.48,129.72,832.48,,541.11,,,percent of total billed charges,,,,,,,,,,,,,,,707.61,,,percent of total billed charges,,,,,,249.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,391.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,158.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,158.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,624.36,,,percent of total billed charges,,,,,,582.74,,,percent of total billed charges,,,,,,582.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,541.11,,,percent of total billed charges,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,832.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,582.74,,,percent of total billed charges,,,,,,457.86,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,832.48,,,percent of total billed charges,,,,,,580.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,591.06,,,percent of total billed charges,,,,,,,,,,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,582.74,,,percent of total billed charges,,,,,,499.49,,,percent of total billed charges,,,,,,374.62,,,percent of total billed charges,,,,,,,,,,,,,,,707.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.86,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,832.48,,,percent of total billed charges,,,,,,832.48,,,percent of total billed charges,,,,,,457.86,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,832.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,832.48,,,percent of total billed charges,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,624.36,,,percent of total billed charges,,,,,,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,832.48,,,percent of total billed charges,,,,,,374.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,457.86,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,832.48,,,fee schedule,,,,,,832.48,,,percent of total billed charges,,,,,,832.48,,,percent of total billed charges,,,,,,832.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,832.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,707.61,,,percent of total billed charges,,,,,,624.36,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI STRT TI 12H 2.4 X 72,24880,CDM,0278,RC,,,,,,inpatient,facility,,,919.34,919.34,413.7,919.34,,,,,,,,,,,,,,,,,,,,781.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,735.47,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,689.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,505.64,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,555.74,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",652.73,,,percent of total billed charges,,,,,,,,,,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,643.54,,,percent of total billed charges,,,,,,551.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,781.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.64,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,505.64,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,919.34,,,percent of total billed charges,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,689.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,919.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,413.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,781.44,,,percent of total billed charges,,,,,,597.57,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI STRT TI 12H 2.4 X 72,24880,CDM,0278,RC,,,,,,outpatient,facility,,,919.34,919.34,129.72,919.34,,597.57,,,percent of total billed charges,,,,,,,,,,,,,,,781.44,,,percent of total billed charges,,,,,,275.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,432.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,174.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,174.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,689.5,,,percent of total billed charges,,,,,,643.54,,,percent of total billed charges,,,,,,643.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,597.57,,,percent of total billed charges,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,919.34,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,643.54,,,percent of total billed charges,,,,,,505.64,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,919.34,,,percent of total billed charges,,,,,,641.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,652.73,,,percent of total billed charges,,,,,,,,,,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,643.54,,,percent of total billed charges,,,,,,551.6,,,percent of total billed charges,,,,,,413.7,,,percent of total billed charges,,,,,,,,,,,,,,,781.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.64,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,919.34,,,percent of total billed charges,,,,,,919.34,,,percent of total billed charges,,,,,,505.64,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,919.34,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,919.34,,,percent of total billed charges,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,689.5,,,percent of total billed charges,,,,,,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,919.34,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,919.34,,,percent of total billed charges,,,,,,413.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,505.64,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,919.34,,,fee schedule,,,,,,919.34,,,percent of total billed charges,,,,,,919.34,,,percent of total billed charges,,,,,,919.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,919.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,781.44,,,percent of total billed charges,,,,,,689.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI T TI 2H 8H 2.4 X 54,24881,CDM,0278,RC,,,,,,inpatient,facility,,,1311.5,1311.5,590.18,1311.5,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,983.62,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,721.33,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,792.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",931.16,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,918.05,,,percent of total billed charges,,,,,,786.9,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,983.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,590.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,852.48,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI T TI 2H 8H 2.4 X 54,24881,CDM,0278,RC,,,,,,outpatient,facility,,,1311.5,1311.5,129.72,1311.5,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,393.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,249.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,983.62,,,percent of total billed charges,,,,,,918.05,,,percent of total billed charges,,,,,,918.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,852.48,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1311.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,918.05,,,percent of total billed charges,,,,,,721.33,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,914.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,931.16,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,918.05,,,percent of total billed charges,,,,,,786.9,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,983.62,,,percent of total billed charges,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,,percent of total billed charges,,,,,,590.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1311.5,,,fee schedule,,,,,,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.77,,,percent of total billed charges,,,,,,983.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI T TI 3H 8H 2.4 X 54,24882,CDM,0278,RC,,,,,,inpatient,facility,,,1311.5,1311.5,590.18,1311.5,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,983.62,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,721.33,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,792.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",931.16,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,918.05,,,percent of total billed charges,,,,,,786.9,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,983.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,590.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,852.48,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI T TI 3H 8H 2.4 X 54,24882,CDM,0278,RC,,,,,,outpatient,facility,,,1311.5,1311.5,129.72,1311.5,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,393.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,249.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,983.62,,,percent of total billed charges,,,,,,918.05,,,percent of total billed charges,,,,,,918.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,852.48,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1311.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,918.05,,,percent of total billed charges,,,,,,721.33,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,914.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,931.16,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,918.05,,,percent of total billed charges,,,,,,786.9,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,983.62,,,percent of total billed charges,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,,percent of total billed charges,,,,,,590.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1311.5,,,fee schedule,,,,,,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.77,,,percent of total billed charges,,,,,,983.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI Y TI 3H 8H 2.4 X 56,24883,CDM,0278,RC,,,,,,inpatient,facility,,,1311.5,1311.5,590.18,1311.5,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1049.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,983.62,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,721.33,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,792.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",931.16,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,918.05,,,percent of total billed charges,,,,,,786.9,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,983.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,590.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,852.48,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI Y TI 3H 8H 2.4 X 56,24883,CDM,0278,RC,,,,,,outpatient,facility,,,1311.5,1311.5,129.72,1311.5,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1114.77,,,percent of total billed charges,,,,,,393.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,249.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,249.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,983.62,,,percent of total billed charges,,,,,,918.05,,,percent of total billed charges,,,,,,918.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,852.48,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1311.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,918.05,,,percent of total billed charges,,,,,,721.33,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,914.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,931.16,,,percent of total billed charges,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,918.05,,,percent of total billed charges,,,,,,786.9,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,721.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,983.62,,,percent of total billed charges,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1311.5,,,percent of total billed charges,,,,,,590.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1311.5,,,fee schedule,,,,,,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,1311.5,,,percent of total billed charges,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,721.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1311.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.77,,,percent of total billed charges,,,,,,983.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR RT TI 8H 2.4 X 57,24884,CDM,0278,RC,,,,,,inpatient,facility,,,1191.1,1191.1,536,1191.1,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.88,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,893.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,655.11,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,720.02,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",845.68,,,percent of total billed charges,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,833.77,,,percent of total billed charges,,,,,,714.66,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1191.1,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,893.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1191.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,536,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,774.21,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR RT TI 8H 2.4 X 57,24884,CDM,0278,RC,,,,,,outpatient,facility,,,1191.1,1191.1,129.72,1191.1,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,357.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,226.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,893.32,,,percent of total billed charges,,,,,,833.77,,,percent of total billed charges,,,,,,833.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,774.21,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1191.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,833.77,,,percent of total billed charges,,,,,,655.11,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,,percent of total billed charges,,,,,,830.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,845.68,,,percent of total billed charges,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,833.77,,,percent of total billed charges,,,,,,714.66,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,,percent of total billed charges,,,,,,1191.1,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1191.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,893.32,,,percent of total billed charges,,,,,,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1191.1,,,percent of total billed charges,,,,,,536,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,893.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1191.1,,,fee schedule,,,,,,1191.1,,,percent of total billed charges,,,,,,1191.1,,,percent of total billed charges,,,,,,1191.1,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1012.44,,,percent of total billed charges,,,,,,893.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI CONDYLAR LT TI 8H 2.4 X 57,24885,CDM,0278,RC,,,,,,inpatient,facility,,,1191.1,1191.1,536,1191.1,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,952.88,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,893.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,655.11,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,720.02,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",845.68,,,percent of total billed charges,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,833.77,,,percent of total billed charges,,,,,,714.66,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1191.1,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,893.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1191.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,536,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,774.21,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI CONDYLAR LT TI 8H 2.4 X 57,24885,CDM,0278,RC,,,,,,outpatient,facility,,,1191.1,1191.1,129.72,1191.1,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,357.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,226.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,226.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,893.32,,,percent of total billed charges,,,,,,833.77,,,percent of total billed charges,,,,,,833.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,774.21,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1191.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,833.77,,,percent of total billed charges,,,,,,655.11,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,,percent of total billed charges,,,,,,830.79,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,845.68,,,percent of total billed charges,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,833.77,,,percent of total billed charges,,,,,,714.66,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1012.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,655.11,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,,percent of total billed charges,,,,,,1191.1,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1191.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,893.32,,,percent of total billed charges,,,,,,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1191.1,,,percent of total billed charges,,,,,,536,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,893.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1191.1,,,fee schedule,,,,,,1191.1,,,percent of total billed charges,,,,,,1191.1,,,percent of total billed charges,,,,,,1191.1,,,percent of total billed charges,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,655.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1191.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1012.44,,,percent of total billed charges,,,,,,893.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI LC DCP TI 4H 2.4 X 31,24886,CDM,0278,RC,,,,,,inpatient,facility,,,1123.16,1123.16,505.42,1123.16,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,954.69,,,percent of total billed charges,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,898.53,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,842.37,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,617.74,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,678.95,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",797.44,,,percent of total billed charges,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,786.21,,,percent of total billed charges,,,,,,673.9,,,percent of total billed charges,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,954.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.74,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1123.16,,,percent of total billed charges,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,842.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1123.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,505.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,954.69,,,percent of total billed charges,,,,,,730.05,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI LC DCP TI 4H 2.4 X 31,24886,CDM,0278,RC,,,,,,outpatient,facility,,,1123.16,1123.16,129.72,1123.16,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,954.69,,,percent of total billed charges,,,,,,336.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,213.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,213.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,842.37,,,percent of total billed charges,,,,,,786.21,,,percent of total billed charges,,,,,,786.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,730.05,,,percent of total billed charges,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1123.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,786.21,,,percent of total billed charges,,,,,,617.74,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1123.16,,,percent of total billed charges,,,,,,783.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,797.44,,,percent of total billed charges,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,786.21,,,percent of total billed charges,,,,,,673.9,,,percent of total billed charges,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,954.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,617.74,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1123.16,,,percent of total billed charges,,,,,,1123.16,,,percent of total billed charges,,,,,,617.74,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1123.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1123.16,,,percent of total billed charges,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,842.37,,,percent of total billed charges,,,,,,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1123.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1123.16,,,percent of total billed charges,,,,,,505.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,842.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1123.16,,,fee schedule,,,,,,1123.16,,,percent of total billed charges,,,,,,1123.16,,,percent of total billed charges,,,,,,1123.16,,,percent of total billed charges,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,617.74,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1123.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,954.69,,,percent of total billed charges,,,,,,842.37,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI LC DCP TI 6H 2.4 X 47,24887,CDM,0278,RC,,,,,,inpatient,facility,,,1266.78,1266.78,570.05,1266.78,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1076.76,,,percent of total billed charges,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1013.42,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,950.09,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,696.73,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,765.77,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",899.41,,,percent of total billed charges,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,886.75,,,percent of total billed charges,,,,,,760.07,,,percent of total billed charges,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1076.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.73,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.78,,,percent of total billed charges,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,950.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1266.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,570.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1076.76,,,percent of total billed charges,,,,,,823.41,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI LC DCP TI 6H 2.4 X 47,24887,CDM,0278,RC,,,,,,outpatient,facility,,,1266.78,1266.78,129.72,1266.78,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1076.76,,,percent of total billed charges,,,,,,380.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,240.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,240.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,950.09,,,percent of total billed charges,,,,,,886.75,,,percent of total billed charges,,,,,,886.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,823.41,,,percent of total billed charges,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1266.78,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,886.75,,,percent of total billed charges,,,,,,696.73,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1266.78,,,percent of total billed charges,,,,,,883.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,899.41,,,percent of total billed charges,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,886.75,,,percent of total billed charges,,,,,,760.07,,,percent of total billed charges,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1076.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,696.73,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1266.78,,,percent of total billed charges,,,,,,1266.78,,,percent of total billed charges,,,,,,696.73,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.78,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1266.78,,,percent of total billed charges,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,950.08,,,percent of total billed charges,,,,,,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1266.78,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1266.78,,,percent of total billed charges,,,,,,570.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,950.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1266.78,,,fee schedule,,,,,,1266.78,,,percent of total billed charges,,,,,,1266.78,,,percent of total billed charges,,,,,,1266.78,,,percent of total billed charges,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,696.73,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1266.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1076.76,,,percent of total billed charges,,,,,,950.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN MINI LC DCP TI 8H 2.4 X 63,24888,CDM,0278,RC,,,,,,inpatient,facility,,,1369.12,1369.12,616.1,1369.12,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1163.75,,,percent of total billed charges,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1095.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1026.84,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,753.02,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,827.63,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",972.08,,,percent of total billed charges,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,958.38,,,percent of total billed charges,,,,,,821.47,,,percent of total billed charges,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,753.02,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1369.12,,,percent of total billed charges,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1026.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1369.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,616.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.75,,,percent of total billed charges,,,,,,889.93,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN MINI LC DCP TI 8H 2.4 X 63,24888,CDM,0278,RC,,,,,,outpatient,facility,,,1369.12,1369.12,129.72,1369.12,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1163.75,,,percent of total billed charges,,,,,,410.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,260.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,260.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1026.84,,,percent of total billed charges,,,,,,958.38,,,percent of total billed charges,,,,,,958.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,889.93,,,percent of total billed charges,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1369.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,958.38,,,percent of total billed charges,,,,,,753.02,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1369.12,,,percent of total billed charges,,,,,,954.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,972.08,,,percent of total billed charges,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,958.38,,,percent of total billed charges,,,,,,821.47,,,percent of total billed charges,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,753.02,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1369.12,,,percent of total billed charges,,,,,,1369.12,,,percent of total billed charges,,,,,,753.02,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1369.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1369.12,,,percent of total billed charges,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1026.84,,,percent of total billed charges,,,,,,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1369.12,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1369.12,,,percent of total billed charges,,,,,,616.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1026.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1369.12,,,fee schedule,,,,,,1369.12,,,percent of total billed charges,,,,,,1369.12,,,percent of total billed charges,,,,,,1369.12,,,percent of total billed charges,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,753.02,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1369.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1163.75,,,percent of total billed charges,,,,,,1026.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JR4 8FR .088 X 100,24983,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JR4 8FR .088 X 100,24983,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB MPA1 7FR .078 X 100,24999,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB MPA1 7FR .078 X 100,24999,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB MPA1 SH 7FR .078 X 100  i,25033,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB MPA1 SH 7FR .078 X 100  i,25033,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB HS 7FR .078 X 100  i,25034,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB HS 7FR .078 X 100  i,25034,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB HS SH 7FR .078 X 100  i,25035,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB HS SH 7FR .078 X 100  i,25035,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB LCB SH 7FR .078 X 100  i,25036,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB LCB SH 7FR .078 X 100  i,25036,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB LCB 7FR .078 X 100  i,25037,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB LCB 7FR .078 X 100  i,25037,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB RCB 7FR .078 X 100  i,25039,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB RCB 7FR .078 X 100  i,25039,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB IM 7FR .078 X 100  i,25041,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB IM 7FR .078 X 100  i,25041,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB MPA1 SH 8FR .088 X 100,25055,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB MPA1 SH 8FR .088 X 100,25055,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB AL1 SH 8FR .088 X 100,25064,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB AL1 SH 8FR .088 X 100,25064,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XBLAD4 7FR .078 X 100  i,25078,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XBLAD4 7FR .078 X 100  i,25078,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XBLAD3.5 7FR .078 X 100  i,25079,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XBLAD3.5 7FR .078 X 100  i,25079,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JL3.5 7FR .078 X 100  i,25080,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JL3.5 7FR .078 X 100  i,25080,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JL3.5 SH 7FR .078 X 100  i,25081,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JL3.5 SH 7FR .078 X 100  i,25081,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JL4 7FR .078 X 100  i,25084,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JL4 7FR .078 X 100  i,25084,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JL4 ST 7FR .078 X 100  i,25085,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JL4 ST 7FR .078 X 100  i,25085,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JL4 SH 7FR .078 X 100  i,25086,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JL4 SH 7FR .078 X 100  i,25086,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JL4.5 7FR .078 X 100  i,25088,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JL4.5 7FR .078 X 100  i,25088,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JL5 7FR .078 X 100  i,25090,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JL5 7FR .078 X 100  i,25090,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB AL1 7FR .078 X 100  i,25091,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB AL1 7FR .078 X 100  i,25091,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB AL1 SH 7FR .078 X 100  i,25094,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB AL1 SH 7FR .078 X 100  i,25094,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB AL1.5 7FR .078 X 100,25095,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB AL1.5 7FR .078 X 100,25095,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB AL2 7FR .078 X 100  i,25097,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB AL2 7FR .078 X 100  i,25097,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB AL2 SH 7FR .078 X 100  i,25098,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB AL2 SH 7FR .078 X 100  i,25098,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XB3 7FR .078 X 100  i,25100,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XB3 7FR .078 X 100  i,25100,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XB3 SH 7FR .078 X 100  i,25101,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XB3 SH 7FR .078 X 100  i,25101,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XB3.5 7FR .078 X 100  i,25102,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XB3.5 7FR .078 X 100  i,25102,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XB3.5 SH 7FR .078 X 100  i,25103,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XB3.5 SH 7FR .078 X 100  i,25103,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XB4 7FR .078 X 100  i,25104,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XB4 7FR .078 X 100  i,25104,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XB4 SH 7FR .078 X 100  i,25105,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XB4 SH 7FR .078 X 100  i,25105,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB XB4.5 7FR .078 X 100  i,25106,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB XB4.5 7FR .078 X 100  i,25106,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JR3.5 7FR .078 X 100  i,25107,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JR3.5 7FR .078 X 100  i,25107,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JR3.5 SH 7FR .078 X 100  i,25108,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JR3.5 SH 7FR .078 X 100  i,25108,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JR4 7FR .078 X 100  i,25109,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JR4 7FR .078 X 100  i,25109,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JR4 SH 7FR .078 X 100  i,25110,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JR4 SH 7FR .078 X 100  i,25110,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JR5 7FR .078 X 100  i,25111,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JR5 7FR .078 X 100  i,25111,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB AR1 7FR .078 X 100  i,25113,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB AR1 7FR .078 X 100  i,25113,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB AR1 SH 7FR .078 X 100  i,25114,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB AR1 SH 7FR .078 X 100  i,25114,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JL4.5 8FR .088 X 100,25128,CDM,0272,RC,,,,,,inpatient,facility,,,133.66,133.66,60.15,133.66,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JL4.5 8FR .088 X 100,25128,CDM,0272,RC,,,,,,outpatient,facility,,,133.66,133.66,25.4,1016,,86.88,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,40.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.24,,,percent of total billed charges,,,,,,93.56,,,percent of total billed charges,,,,,,93.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.88,,,percent of total billed charges,,,,,,32.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.22,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.56,,,percent of total billed charges,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,93.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.56,,,percent of total billed charges,,,,,,80.2,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,113.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,57.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.66,,,percent of total billed charges,,,,,,60.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.66,,,fee schedule,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,133.66,,,percent of total billed charges,,,,,,64.16,,,percent of total billed charges,,,,,,,,,,,,,,,78.86,,,percent of total billed charges,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.66,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.61,,,percent of total billed charges,,,,,,100.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JR3.5 ST SH 8FR .088 X 100,25171,CDM,0272,RC,,,,,,inpatient,facility,,,129.5,129.5,58.27,129.5,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,90.65,,,percent of total billed charges,,,,,,77.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JR3.5 ST SH 8FR .088 X 100,25171,CDM,0272,RC,,,,,,outpatient,facility,,,129.5,129.5,24.61,1016,,84.17,,,percent of total billed charges,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,38.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,24.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,97.12,,,percent of total billed charges,,,,,,90.65,,,percent of total billed charges,,,,,,90.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,84.17,,,percent of total billed charges,,,,,,31.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",87.41,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,129.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.39,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.65,,,percent of total billed charges,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,90.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,91.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,90.65,,,percent of total billed charges,,,,,,77.7,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,55.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.12,,,percent of total billed charges,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,fee schedule,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,62.16,,,percent of total billed charges,,,,,,,,,,,,,,,76.41,,,percent of total billed charges,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.08,,,percent of total billed charges,,,,,,97.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE IX SHINOBI PLUS STEER STRT .014 X 180,25180,CDM,0272,RC,,,,,,inpatient,facility,,,206.5,206.5,92.92,206.5,,,,,,,,,,,,,,,,,,,,175.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,144.55,,,percent of total billed charges,,,,,,123.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,175.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,206.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,92.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.52,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE IX SHINOBI PLUS STEER STRT .014 X 180,25180,CDM,0272,RC,,,,,,outpatient,facility,,,206.5,206.5,39.23,1016,,134.22,,,percent of total billed charges,,,,,,,,,,,,,,,175.52,,,percent of total billed charges,,,,,,61.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,39.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,39.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,154.88,,,percent of total billed charges,,,,,,144.55,,,percent of total billed charges,,,,,,144.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,134.22,,,percent of total billed charges,,,,,,49.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",139.39,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,206.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,86.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",144.55,,,percent of total billed charges,,,,,,,,,,,,,,,206.5,,,percent of total billed charges,,,,,,144.03,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,146.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,144.55,,,percent of total billed charges,,,,,,123.9,,,percent of total billed charges,,,,,,92.92,,,percent of total billed charges,,,,,,,,,,,,,,,175.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.5,,,percent of total billed charges,,,,,,206.5,,,percent of total billed charges,,,,,,88.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,206.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,206.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.88,,,percent of total billed charges,,,,,,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,206.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,206.5,,,percent of total billed charges,,,,,,92.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.5,,,fee schedule,,,,,,206.5,,,percent of total billed charges,,,,,,206.5,,,percent of total billed charges,,,,,,206.5,,,percent of total billed charges,,,,,,99.12,,,percent of total billed charges,,,,,,,,,,,,,,,121.83,,,percent of total billed charges,,,,,,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,206.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,175.52,,,percent of total billed charges,,,,,,154.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE SYN TH 1.25MM,25238,CDM,0272,RC,,,,,,inpatient,facility,,,78.12,78.12,35.15,78.12,,,,,,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,,,,46.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE SYN TH 1.25MM,25238,CDM,0272,RC,,,,,,outpatient,facility,,,78.12,78.12,14.84,1016,,50.78,,,percent of total billed charges,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,23.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,36.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,58.59,,,percent of total billed charges,,,,,,54.68,,,percent of total billed charges,,,,,,54.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,50.78,,,percent of total billed charges,,,,,,18.75,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",52.73,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,78.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,32.81,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",54.68,,,percent of total billed charges,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,54.49,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,55.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,54.68,,,percent of total billed charges,,,,,,46.87,,,percent of total billed charges,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,66.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,78.12,,,percent of total billed charges,,,,,,33.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,78.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,78.12,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,78.12,,,percent of total billed charges,,,,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.12,,,fee schedule,,,,,,78.12,,,percent of total billed charges,,,,,,78.12,,,percent of total billed charges,,,,,,78.12,,,percent of total billed charges,,,,,,37.5,,,percent of total billed charges,,,,,,,,,,,,,,,46.09,,,percent of total billed charges,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,78.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,66.4,,,percent of total billed charges,,,,,,58.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEM DEP KNEE PFC SIGMA SUB LT SZ5,25240,CDM,0278,RC,,,,,,inpatient,facility,,,3490,3490,1570.5,3490,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2966.5,,,percent of total billed charges,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2792,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2617.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2109.7,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2477.9,,,percent of total billed charges,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2443,,,percent of total billed charges,,,,,,2094,,,percent of total billed charges,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2966.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3490,,,percent of total billed charges,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2617.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3490,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1570.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2966.5,,,percent of total billed charges,,,,,,2268.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEM DEP KNEE PFC SIGMA SUB LT SZ5,25240,CDM,0278,RC,,,,,,outpatient,facility,,,3490,3490,129.72,3490,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2966.5,,,percent of total billed charges,,,,,,1047,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,663.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,663.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2617.5,,,percent of total billed charges,,,,,,2443,,,percent of total billed charges,,,,,,2443,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2268.5,,,percent of total billed charges,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3490,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2443,,,percent of total billed charges,,,,,,1919.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3490,,,percent of total billed charges,,,,,,2434.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2477.9,,,percent of total billed charges,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2443,,,percent of total billed charges,,,,,,2094,,,percent of total billed charges,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2966.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1919.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3490,,,percent of total billed charges,,,,,,3490,,,percent of total billed charges,,,,,,1919.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3490,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3490,,,percent of total billed charges,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2617.5,,,percent of total billed charges,,,,,,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3490,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3490,,,percent of total billed charges,,,,,,1570.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2617.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3490,,,fee schedule,,,,,,3490,,,percent of total billed charges,,,,,,3490,,,percent of total billed charges,,,,,,3490,,,percent of total billed charges,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1919.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3490,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2966.5,,,percent of total billed charges,,,,,,2617.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BASEPLATE STR TIB DURACON UNIV N BEADED LRG 2,25251,CDM,0278,RC,,,,,,inpatient,facility,,,3096.5,3096.5,1393.42,3096.5,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2632.02,,,percent of total billed charges,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2477.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2322.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1703.08,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1871.83,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2198.52,,,percent of total billed charges,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2167.55,,,percent of total billed charges,,,,,,1857.9,,,percent of total billed charges,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2632.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1703.08,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3096.5,,,percent of total billed charges,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2322.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3096.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2632.02,,,percent of total billed charges,,,,,,2012.73,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BASEPLATE STR TIB DURACON UNIV N BEADED LRG 2,25251,CDM,0278,RC,,,,,,outpatient,facility,,,3096.5,3096.5,129.72,3096.5,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2632.02,,,percent of total billed charges,,,,,,928.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,588.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,588.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2322.38,,,percent of total billed charges,,,,,,2167.55,,,percent of total billed charges,,,,,,2167.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2012.73,,,percent of total billed charges,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3096.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2167.55,,,percent of total billed charges,,,,,,1703.08,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3096.5,,,percent of total billed charges,,,,,,2159.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2198.52,,,percent of total billed charges,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2167.55,,,percent of total billed charges,,,,,,1857.9,,,percent of total billed charges,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2632.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1703.08,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3096.5,,,percent of total billed charges,,,,,,3096.5,,,percent of total billed charges,,,,,,1703.08,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3096.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3096.5,,,percent of total billed charges,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2322.38,,,percent of total billed charges,,,,,,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3096.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3096.5,,,percent of total billed charges,,,,,,1393.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2322.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3096.5,,,fee schedule,,,,,,3096.5,,,percent of total billed charges,,,,,,3096.5,,,percent of total billed charges,,,,,,3096.5,,,percent of total billed charges,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1703.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3096.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2632.02,,,percent of total billed charges,,,,,,2322.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WIRE ZIM BEAD LOOP LUQUE 16X20,25252,CDM,0278,RC,,,,,,inpatient,facility,,,88,88,39.6,88,,,,,,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.2,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.6,,,percent of total billed charges,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,57.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WIRE ZIM BEAD LOOP LUQUE 16X20,25252,CDM,0278,RC,,,,,,outpatient,facility,,,88,88,16.72,138.8,,57.2,,,percent of total billed charges,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,26.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66,,,percent of total billed charges,,,,,,61.6,,,percent of total billed charges,,,,,,61.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.2,,,percent of total billed charges,,,,,,21.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.96,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.6,,,percent of total billed charges,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,61.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.6,,,percent of total billed charges,,,,,,52.8,,,percent of total billed charges,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,88,,,percent of total billed charges,,,,,,37.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88,,,percent of total billed charges,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,fee schedule,,,,,,88,,,percent of total billed charges,,,,,,88,,,percent of total billed charges,,,,,,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.8,,,percent of total billed charges,,,,,,66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WIRE ZIM LOOP BEAD LUQE 16X30,25255,CDM,0278,RC,,,,,,inpatient,facility,,,88,88,39.6,88,,,,,,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,66,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.2,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",62.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.6,,,percent of total billed charges,,,,,,52.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,57.2,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WIRE ZIM LOOP BEAD LUQE 16X30,25255,CDM,0278,RC,,,,,,outpatient,facility,,,88,88,16.72,138.8,,57.2,,,percent of total billed charges,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,26.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,16.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.4,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66,,,percent of total billed charges,,,,,,61.6,,,percent of total billed charges,,,,,,61.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,57.2,,,percent of total billed charges,,,,,,21.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.96,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.6,,,percent of total billed charges,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,61.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.6,,,percent of total billed charges,,,,,,52.8,,,percent of total billed charges,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,88,,,percent of total billed charges,,,,,,37.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,88,,,percent of total billed charges,,,,,,39.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,,fee schedule,,,,,,88,,,percent of total billed charges,,,,,,88,,,percent of total billed charges,,,,,,88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.8,,,percent of total billed charges,,,,,,66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATELLA DEP DOME 38MM NC,25284,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATELLA DEP DOME 38MM NC,25284,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INSERT DEP TIBIA PFC STAB 4 X 10.0,25285,CDM,0278,RC,,,,,,inpatient,facility,,,1150,1150,517.5,1150,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,977.5,,,percent of total billed charges,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,920,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,862.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,632.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,695.18,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",816.5,,,percent of total billed charges,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,805,,,percent of total billed charges,,,,,,690,,,percent of total billed charges,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,977.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150,,,percent of total billed charges,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,862.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1150,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,517.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,977.5,,,percent of total billed charges,,,,,,747.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
INSERT DEP TIBIA PFC STAB 4 X 10.0,25285,CDM,0278,RC,,,,,,outpatient,facility,,,1150,1150,129.72,1150,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,977.5,,,percent of total billed charges,,,,,,345,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,218.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,218.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,862.5,,,percent of total billed charges,,,,,,805,,,percent of total billed charges,,,,,,805,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,747.5,,,percent of total billed charges,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1150,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,805,,,percent of total billed charges,,,,,,632.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1150,,,percent of total billed charges,,,,,,802.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,816.5,,,percent of total billed charges,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,805,,,percent of total billed charges,,,,,,690,,,percent of total billed charges,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,977.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1150,,,percent of total billed charges,,,,,,1150,,,percent of total billed charges,,,,,,632.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1150,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1150,,,percent of total billed charges,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,862.5,,,percent of total billed charges,,,,,,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1150,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1150,,,percent of total billed charges,,,,,,517.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1150,,,fee schedule,,,,,,1150,,,percent of total billed charges,,,,,,1150,,,percent of total billed charges,,,,,,1150,,,percent of total billed charges,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,632.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1150,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,977.5,,,percent of total billed charges,,,,,,862.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT SS ST 4.5 X 56,25286,CDM,0278,RC,,,,,,inpatient,facility,,,68.8,68.8,30.96,68.8,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,51.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT SS ST 4.5 X 56,25286,CDM,0278,RC,,,,,,outpatient,facility,,,68.8,68.8,13.07,138.8,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,20.64,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,51.6,,,percent of total billed charges,,,,,,48.16,,,percent of total billed charges,,,,,,48.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.72,,,percent of total billed charges,,,,,,16.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,68.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",48.16,,,percent of total billed charges,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,47.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,48.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,48.16,,,percent of total billed charges,,,,,,41.28,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,58.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,29.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,68.8,,,percent of total billed charges,,,,,,30.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,,fee schedule,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,68.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,68.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,58.48,,,percent of total billed charges,,,,,,51.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS PART TH 4.5 X 56,25287,CDM,0278,RC,,,,,,inpatient,facility,,,318.24,318.24,143.21,318.24,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.59,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,238.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",225.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.77,,,percent of total billed charges,,,,,,190.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,206.86,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS PART TH 4.5 X 56,25287,CDM,0278,RC,,,,,,outpatient,facility,,,318.24,318.24,60.47,318.24,,206.86,,,percent of total billed charges,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,95.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,149.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,60.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,238.68,,,percent of total billed charges,,,,,,222.77,,,percent of total billed charges,,,,,,222.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,206.86,,,percent of total billed charges,,,,,,76.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,318.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",222.77,,,percent of total billed charges,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,221.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,225.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.77,,,percent of total billed charges,,,,,,190.94,,,percent of total billed charges,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,136.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,,percent of total billed charges,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,fee schedule,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,270.5,,,percent of total billed charges,,,,,,238.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS PART TH 4.5 X 44,25288,CDM,0278,RC,,,,,,inpatient,facility,,,318.24,318.24,143.21,318.24,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.59,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,238.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",225.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.77,,,percent of total billed charges,,,,,,190.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,206.86,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS PART TH 4.5 X 44,25288,CDM,0278,RC,,,,,,outpatient,facility,,,318.24,318.24,60.47,318.24,,206.86,,,percent of total billed charges,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,95.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,149.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,60.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,238.68,,,percent of total billed charges,,,,,,222.77,,,percent of total billed charges,,,,,,222.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,206.86,,,percent of total billed charges,,,,,,76.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,318.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",222.77,,,percent of total billed charges,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,221.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,225.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.77,,,percent of total billed charges,,,,,,190.94,,,percent of total billed charges,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,136.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,,percent of total billed charges,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,fee schedule,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,270.5,,,percent of total billed charges,,,,,,238.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS PART TH 4.5 X 40,25289,CDM,0278,RC,,,,,,inpatient,facility,,,318.24,318.24,143.21,318.24,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.59,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,238.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",225.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.77,,,percent of total billed charges,,,,,,190.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,206.86,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS PART TH 4.5 X 40,25289,CDM,0278,RC,,,,,,outpatient,facility,,,318.24,318.24,60.47,318.24,,206.86,,,percent of total billed charges,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,95.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,149.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,60.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,175.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,238.68,,,percent of total billed charges,,,,,,222.77,,,percent of total billed charges,,,,,,222.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,206.86,,,percent of total billed charges,,,,,,76.38,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,318.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",222.77,,,percent of total billed charges,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,221.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,225.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,222.77,,,percent of total billed charges,,,,,,190.94,,,percent of total billed charges,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,270.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,136.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,318.24,,,percent of total billed charges,,,,,,143.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,238.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,,fee schedule,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,318.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,318.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,270.5,,,percent of total billed charges,,,,,,238.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WASHER SYN MINI 10MM,25290,CDM,0278,RC,,,,,,inpatient,facility,,,42.48,42.48,19.12,42.48,,,,,,,,,,,,,,,,,,,,36.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,31.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.68,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",30.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,29.74,,,percent of total billed charges,,,,,,25.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,36.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,42.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,19.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.11,,,percent of total billed charges,,,,,,27.61,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WASHER SYN MINI 10MM,25290,CDM,0278,RC,,,,,,outpatient,facility,,,42.48,42.48,8.07,138.8,,27.61,,,percent of total billed charges,,,,,,,,,,,,,,,36.11,,,percent of total billed charges,,,,,,12.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,19.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.36,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,8.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,23.36,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23.36,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.36,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31.86,,,percent of total billed charges,,,,,,29.74,,,percent of total billed charges,,,,,,29.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,,,,10.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,42.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,17.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",29.74,,,percent of total billed charges,,,,,,,,,,,,,,,42.48,,,percent of total billed charges,,,,,,29.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,30.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,29.74,,,percent of total billed charges,,,,,,25.49,,,percent of total billed charges,,,,,,19.12,,,percent of total billed charges,,,,,,,,,,,,,,,36.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.48,,,percent of total billed charges,,,,,,42.48,,,percent of total billed charges,,,,,,18.27,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,42.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,42.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.86,,,percent of total billed charges,,,,,,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,42.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,42.48,,,percent of total billed charges,,,,,,19.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.48,,,fee schedule,,,,,,42.48,,,percent of total billed charges,,,,,,42.48,,,percent of total billed charges,,,,,,42.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,42.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.11,,,percent of total billed charges,,,,,,31.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC 3 FLUTE CALIB 3.2 X 215,25295,CDM,0272,RC,,,,,,inpatient,facility,,,743.47,743.47,334.56,743.47,,,,,,,,,,,,,,,,,,,,631.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,527.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,520.43,,,percent of total billed charges,,,,,,446.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,631.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,743.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,334.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.95,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC 3 FLUTE CALIB 3.2 X 215,25295,CDM,0272,RC,,,,,,outpatient,facility,,,743.47,743.47,129.72,1016,,483.26,,,percent of total billed charges,,,,,,,,,,,,,,,631.95,,,percent of total billed charges,,,,,,223.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,349.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,141.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,557.6,,,percent of total billed charges,,,,,,520.43,,,percent of total billed charges,,,,,,520.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,483.26,,,percent of total billed charges,,,,,,178.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",501.84,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,743.47,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,312.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",520.43,,,percent of total billed charges,,,,,,,,,,,,,,,743.47,,,percent of total billed charges,,,,,,518.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,527.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,520.43,,,percent of total billed charges,,,,,,446.08,,,percent of total billed charges,,,,,,334.56,,,percent of total billed charges,,,,,,,,,,,,,,,631.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.47,,,percent of total billed charges,,,,,,743.47,,,percent of total billed charges,,,,,,319.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,743.47,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,743.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.6,,,percent of total billed charges,,,,,,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,743.47,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,743.47,,,percent of total billed charges,,,,,,334.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.47,,,fee schedule,,,,,,743.47,,,percent of total billed charges,,,,,,743.47,,,percent of total billed charges,,,,,,743.47,,,percent of total billed charges,,,,,,356.87,,,percent of total billed charges,,,,,,,,,,,,,,,438.65,,,percent of total billed charges,,,,,,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,743.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,631.95,,,percent of total billed charges,,,,,,557.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN 3 FLUTE BRAD PT 3.2 X 150,25296,CDM,0272,RC,,,,,,inpatient,facility,,,912.03,912.03,410.41,912.03,,,,,,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,638.42,,,percent of total billed charges,,,,,,547.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,410.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN 3 FLUTE BRAD PT 3.2 X 150,25296,CDM,0272,RC,,,,,,outpatient,facility,,,912.03,912.03,129.72,1016,,592.82,,,percent of total billed charges,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,273.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,428.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,173.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,173.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,684.02,,,percent of total billed charges,,,,,,638.42,,,percent of total billed charges,,,,,,638.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,592.82,,,percent of total billed charges,,,,,,218.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",615.62,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,912.03,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,383.05,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",638.42,,,percent of total billed charges,,,,,,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,636.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,647.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,638.42,,,percent of total billed charges,,,,,,547.22,,,percent of total billed charges,,,,,,410.41,,,percent of total billed charges,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,912.03,,,percent of total billed charges,,,,,,392.17,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,912.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.02,,,percent of total billed charges,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,912.03,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,912.03,,,percent of total billed charges,,,,,,410.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,,fee schedule,,,,,,912.03,,,percent of total billed charges,,,,,,912.03,,,percent of total billed charges,,,,,,912.03,,,percent of total billed charges,,,,,,437.77,,,percent of total billed charges,,,,,,,,,,,,,,,538.1,,,percent of total billed charges,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,775.23,,,percent of total billed charges,,,,,,684.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SMI AMBI SUPRA 95DG 10H 204MM,25299,CDM,0278,RC,,,,,,inpatient,facility,,,916,916,412.2,916,,,,,,,,,,,,,,,,,,,,778.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,687,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,503.8,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,553.72,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",650.36,,,percent of total billed charges,,,,,,,,,,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,641.2,,,percent of total billed charges,,,,,,549.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,778.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.8,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,503.8,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,916,,,percent of total billed charges,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,687,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,916,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,412.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,778.6,,,percent of total billed charges,,,,,,595.4,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SMI AMBI SUPRA 95DG 10H 204MM,25299,CDM,0278,RC,,,,,,outpatient,facility,,,916,916,129.72,916,,595.4,,,percent of total billed charges,,,,,,,,,,,,,,,778.6,,,percent of total billed charges,,,,,,274.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,430.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,174.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,174.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,687,,,percent of total billed charges,,,,,,641.2,,,percent of total billed charges,,,,,,641.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,595.4,,,percent of total billed charges,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,916,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,641.2,,,percent of total billed charges,,,,,,503.8,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,916,,,percent of total billed charges,,,,,,638.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,650.36,,,percent of total billed charges,,,,,,,,,,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,641.2,,,percent of total billed charges,,,,,,549.6,,,percent of total billed charges,,,,,,412.2,,,percent of total billed charges,,,,,,,,,,,,,,,778.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.8,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,916,,,percent of total billed charges,,,,,,916,,,percent of total billed charges,,,,,,503.8,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,916,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,916,,,percent of total billed charges,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,687,,,percent of total billed charges,,,,,,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,916,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,916,,,percent of total billed charges,,,,,,412.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,687,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,503.8,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,916,,,fee schedule,,,,,,916,,,percent of total billed charges,,,,,,916,,,percent of total billed charges,,,,,,916,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,916,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,778.6,,,percent of total billed charges,,,,,,687,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP SECUR FIT HA 132DG 8 NC,25317,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP SECUR FIT HA 132DG 8 NC,25317,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATELLA DEP 3 PEG LCS LRG,25319,CDM,0278,RC,,,,,,inpatient,facility,,,1813,1813,815.85,1813,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1450.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1359.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,997.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1095.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1287.23,,,percent of total billed charges,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1269.1,,,percent of total billed charges,,,,,,1087.8,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1813,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1359.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1813,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,815.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1541.05,,,percent of total billed charges,,,,,,1178.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATELLA DEP 3 PEG LCS LRG,25319,CDM,0278,RC,,,,,,outpatient,facility,,,1813,1813,129.72,1813,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1541.05,,,percent of total billed charges,,,,,,543.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,344.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,344.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1359.75,,,percent of total billed charges,,,,,,1269.1,,,percent of total billed charges,,,,,,1269.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1178.45,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1813,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1269.1,,,percent of total billed charges,,,,,,997.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,,percent of total billed charges,,,,,,1264.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1287.23,,,percent of total billed charges,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1269.1,,,percent of total billed charges,,,,,,1087.8,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,,percent of total billed charges,,,,,,1813,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1813,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1359.75,,,percent of total billed charges,,,,,,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1813,,,percent of total billed charges,,,,,,815.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1359.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1813,,,fee schedule,,,,,,1813,,,percent of total billed charges,,,,,,1813,,,percent of total billed charges,,,,,,1813,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1541.05,,,percent of total billed charges,,,,,,1359.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BEARING DEP PLATE ROTAT LCS LRG 15MM,25320,CDM,0278,RC,,,,,,inpatient,facility,,,1253,1253,563.85,1253,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1065.05,,,percent of total billed charges,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1002.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,939.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,689.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,757.44,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",889.63,,,percent of total billed charges,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,877.1,,,percent of total billed charges,,,,,,751.8,,,percent of total billed charges,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1065.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253,,,percent of total billed charges,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,939.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1253,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,563.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1065.05,,,percent of total billed charges,,,,,,814.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BEARING DEP PLATE ROTAT LCS LRG 15MM,25320,CDM,0278,RC,,,,,,outpatient,facility,,,1253,1253,129.72,1253,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1065.05,,,percent of total billed charges,,,,,,375.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,238.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,238.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,939.75,,,percent of total billed charges,,,,,,877.1,,,percent of total billed charges,,,,,,877.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,814.45,,,percent of total billed charges,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1253,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,877.1,,,percent of total billed charges,,,,,,689.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1253,,,percent of total billed charges,,,,,,873.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,889.63,,,percent of total billed charges,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,877.1,,,percent of total billed charges,,,,,,751.8,,,percent of total billed charges,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1065.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,689.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1253,,,percent of total billed charges,,,,,,1253,,,percent of total billed charges,,,,,,689.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1253,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1253,,,percent of total billed charges,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,939.75,,,percent of total billed charges,,,,,,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1253,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1253,,,percent of total billed charges,,,,,,563.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,939.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1253,,,fee schedule,,,,,,1253,,,percent of total billed charges,,,,,,1253,,,percent of total billed charges,,,,,,1253,,,percent of total billed charges,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,689.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1253,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1065.05,,,percent of total billed charges,,,,,,939.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEM DEP KNEE PFC SIGMA SUB RT SZ3,25323,CDM,0278,RC,,,,,,inpatient,facility,,,4800,4800,2160,4800,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,4080,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3840,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3600,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2640,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2901.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3408,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3360,,,percent of total billed charges,,,,,,2880,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,4080,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4800,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2160,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4080,,,percent of total billed charges,,,,,,3120,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEM DEP KNEE PFC SIGMA SUB RT SZ3,25323,CDM,0278,RC,,,,,,outpatient,facility,,,4800,4800,129.72,4800,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4080,,,percent of total billed charges,,,,,,1440,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,912,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,912,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3600,,,percent of total billed charges,,,,,,3360,,,percent of total billed charges,,,,,,3360,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3120,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4800,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,,percent of total billed charges,,,,,,2640,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,3348,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3408,,,percent of total billed charges,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3360,,,percent of total billed charges,,,,,,2880,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4080,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2640,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4800,,,percent of total billed charges,,,,,,2160,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4800,,,fee schedule,,,,,,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,4800,,,percent of total billed charges,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2640,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4800,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4080,,,percent of total billed charges,,,,,,3600,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATELLA DEP DOME 35MM NC,25326,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATELLA DEP DOME 35MM NC,25326,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI STEP 5.0 6.4 X 30,25365,CDM,0278,RC,,,,,,inpatient,facility,,,168.9,168.9,76.01,168.9,,,,,,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.23,,,percent of total billed charges,,,,,,101.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,109.79,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI STEP 5.0 6.4 X 30,25365,CDM,0278,RC,,,,,,outpatient,facility,,,168.9,168.9,32.09,168.9,,109.78,,,percent of total billed charges,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,50.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126.68,,,percent of total billed charges,,,,,,118.23,,,percent of total billed charges,,,,,,118.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.79,,,percent of total billed charges,,,,,,40.54,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.94,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.23,,,percent of total billed charges,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,117.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.23,,,percent of total billed charges,,,,,,101.34,,,percent of total billed charges,,,,,,76.01,,,percent of total billed charges,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,168.9,,,percent of total billed charges,,,,,,72.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.9,,,percent of total billed charges,,,,,,76.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,fee schedule,,,,,,168.9,,,percent of total billed charges,,,,,,168.9,,,percent of total billed charges,,,,,,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.56,,,percent of total billed charges,,,,,,126.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI STEP 5.0 6.4 X 55,25366,CDM,0278,RC,,,,,,inpatient,facility,,,168.9,168.9,76.01,168.9,,,,,,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.1,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.23,,,percent of total billed charges,,,,,,101.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,109.79,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI STEP 5.0 6.4 X 55,25366,CDM,0278,RC,,,,,,outpatient,facility,,,168.9,168.9,32.09,168.9,,109.78,,,percent of total billed charges,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,50.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126.68,,,percent of total billed charges,,,,,,118.23,,,percent of total billed charges,,,,,,118.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.79,,,percent of total billed charges,,,,,,40.54,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,168.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.94,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.23,,,percent of total billed charges,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,117.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.23,,,percent of total billed charges,,,,,,101.34,,,percent of total billed charges,,,,,,76.01,,,percent of total billed charges,,,,,,,,,,,,,,,143.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,168.9,,,percent of total billed charges,,,,,,72.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.9,,,percent of total billed charges,,,,,,76.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,,fee schedule,,,,,,168.9,,,percent of total billed charges,,,,,,168.9,,,percent of total billed charges,,,,,,168.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.56,,,percent of total billed charges,,,,,,126.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI STEP 5.0 6.4 X 85,25367,CDM,0278,RC,,,,,,inpatient,facility,,,178,178,80.1,178,,,,,,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,133.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",126.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.6,,,percent of total billed charges,,,,,,106.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,178,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,80.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,115.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI STEP 5.0 6.4 X 85,25367,CDM,0278,RC,,,,,,outpatient,facility,,,178,178,33.82,178,,115.7,,,percent of total billed charges,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,53.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133.5,,,percent of total billed charges,,,,,,124.6,,,percent of total billed charges,,,,,,124.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.7,,,percent of total billed charges,,,,,,42.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,178,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.76,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.6,,,percent of total billed charges,,,,,,,,,,,,,,,178,,,percent of total billed charges,,,,,,124.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,126.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.6,,,percent of total billed charges,,,,,,106.8,,,percent of total billed charges,,,,,,80.1,,,percent of total billed charges,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,,percent of total billed charges,,,,,,178,,,percent of total billed charges,,,,,,76.54,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,178,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.5,,,percent of total billed charges,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,178,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,178,,,percent of total billed charges,,,,,,80.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,,fee schedule,,,,,,178,,,percent of total billed charges,,,,,,178,,,percent of total billed charges,,,,,,178,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.3,,,percent of total billed charges,,,,,,133.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI STEP 5.0 6.4 X 90,25368,CDM,0278,RC,,,,,,inpatient,facility,,,178,178,80.1,178,,,,,,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,133.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",126.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.6,,,percent of total billed charges,,,,,,106.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,178,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,80.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,115.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI STEP 5.0 6.4 X 90,25368,CDM,0278,RC,,,,,,outpatient,facility,,,178,178,33.82,178,,115.7,,,percent of total billed charges,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,53.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133.5,,,percent of total billed charges,,,,,,124.6,,,percent of total billed charges,,,,,,124.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.7,,,percent of total billed charges,,,,,,42.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,178,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.76,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.6,,,percent of total billed charges,,,,,,,,,,,,,,,178,,,percent of total billed charges,,,,,,124.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,126.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.6,,,percent of total billed charges,,,,,,106.8,,,percent of total billed charges,,,,,,80.1,,,percent of total billed charges,,,,,,,,,,,,,,,151.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,,percent of total billed charges,,,,,,178,,,percent of total billed charges,,,,,,76.54,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,178,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.5,,,percent of total billed charges,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,178,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,178,,,percent of total billed charges,,,,,,80.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,,fee schedule,,,,,,178,,,percent of total billed charges,,,,,,178,,,percent of total billed charges,,,,,,178,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,178,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.3,,,percent of total billed charges,,,,,,133.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SLEEVE DEP FEM PROX ZTT 22B LRG NC,25369,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SLEEVE DEP FEM PROX ZTT 22B LRG NC,25369,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM DEP FEM STD 17 X 22 X 165 NC,25370,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM DEP FEM STD 17 X 22 X 165 NC,25370,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP POLY L 10DG X 28,25371,CDM,0278,RC,,,,,,inpatient,facility,,,1220,1220,549,1220,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1037,,,percent of total billed charges,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,976,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,915,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,671,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,737.49,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",866.2,,,percent of total billed charges,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,854,,,percent of total billed charges,,,,,,732,,,percent of total billed charges,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1037,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1220,,,percent of total billed charges,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,915,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,549,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1037,,,percent of total billed charges,,,,,,793,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP POLY L 10DG X 28,25371,CDM,0278,RC,,,,,,outpatient,facility,,,1220,1220,129.72,1220,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1037,,,percent of total billed charges,,,,,,366,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,231.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,231.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,915,,,percent of total billed charges,,,,,,854,,,percent of total billed charges,,,,,,854,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,793,,,percent of total billed charges,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,854,,,percent of total billed charges,,,,,,671,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1220,,,percent of total billed charges,,,,,,850.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,866.2,,,percent of total billed charges,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,854,,,percent of total billed charges,,,,,,732,,,percent of total billed charges,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1037,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,671,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1220,,,percent of total billed charges,,,,,,1220,,,percent of total billed charges,,,,,,671,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1220,,,percent of total billed charges,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,915,,,percent of total billed charges,,,,,,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1220,,,percent of total billed charges,,,,,,549,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,915,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1220,,,fee schedule,,,,,,1220,,,percent of total billed charges,,,,,,1220,,,percent of total billed charges,,,,,,1220,,,percent of total billed charges,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,671,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1037,,,percent of total billed charges,,,,,,915,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP DEP HIP ACET ZTT 64MM,25372,CDM,0278,RC,,,,,,inpatient,facility,,,2530,2530,1138.5,2530,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2150.5,,,percent of total billed charges,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2024,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1897.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1391.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1529.38,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1796.3,,,percent of total billed charges,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1771,,,percent of total billed charges,,,,,,1518,,,percent of total billed charges,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2150.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1391.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1897.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2530,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1138.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2150.5,,,percent of total billed charges,,,,,,1644.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP DEP HIP ACET ZTT 64MM,25372,CDM,0278,RC,,,,,,outpatient,facility,,,2530,2530,129.72,2530,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2150.5,,,percent of total billed charges,,,,,,759,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,480.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,480.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1897.5,,,percent of total billed charges,,,,,,1771,,,percent of total billed charges,,,,,,1771,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1644.5,,,percent of total billed charges,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2530,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1771,,,percent of total billed charges,,,,,,1391.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,,percent of total billed charges,,,,,,1764.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1796.3,,,percent of total billed charges,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1771,,,percent of total billed charges,,,,,,1518,,,percent of total billed charges,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2150.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1391.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,,1391.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,,percent of total billed charges,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1897.5,,,percent of total billed charges,,,,,,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2530,,,percent of total billed charges,,,,,,1138.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1897.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2530,,,fee schedule,,,,,,2530,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,,2530,,,percent of total billed charges,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1391.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2530,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2150.5,,,percent of total billed charges,,,,,,1897.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PIN DEP INSERT LOCK S ROM 5.0MM,25376,CDM,0278,RC,,,,,,inpatient,facility,,,398,398,179.1,398,,,,,,,,,,,,,,,,,,,,338.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,318.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,298.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.59,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",282.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,278.6,,,percent of total billed charges,,,,,,238.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,338.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,338.3,,,percent of total billed charges,,,,,,258.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PIN DEP INSERT LOCK S ROM 5.0MM,25376,CDM,0278,RC,,,,,,outpatient,facility,,,398,398,75.62,398,,258.7,,,percent of total billed charges,,,,,,,,,,,,,,,338.3,,,percent of total billed charges,,,,,,119.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,218.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,218.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,298.5,,,percent of total billed charges,,,,,,278.6,,,percent of total billed charges,,,,,,278.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,258.7,,,percent of total billed charges,,,,,,95.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",278.6,,,percent of total billed charges,,,,,,,,,,,,,,,398,,,percent of total billed charges,,,,,,277.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,282.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,278.6,,,percent of total billed charges,,,,,,238.8,,,percent of total billed charges,,,,,,179.1,,,percent of total billed charges,,,,,,,,,,,,,,,338.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398,,,percent of total billed charges,,,,,,398,,,percent of total billed charges,,,,,,171.14,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.5,,,percent of total billed charges,,,,,,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398,,,percent of total billed charges,,,,,,179.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,298.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398,,,fee schedule,,,,,,398,,,percent of total billed charges,,,,,,398,,,percent of total billed charges,,,,,,398,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,338.3,,,percent of total billed charges,,,,,,298.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR KNEE SCORPIO PS WAFFLE LFIT RT 9 NC,25383,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR KNEE SCORPIO PS WAFFLE LFIT RT 9 NC,25383,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP DEP HIP SECTOR DURALOC 48MM,25394,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP DEP HIP SECTOR DURALOC 48MM,25394,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR KNEE SCORPIO PS WAFFLE LFIT LT 9 NC,25439,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR KNEE SCORPIO PS WAFFLE LFIT LT 9 NC,25439,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEAD DEP HIP COBALT CHROME 28   8,25483,CDM,0278,RC,,,,,,inpatient,facility,,,2026,2026,911.7,2026,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1620.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1519.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1224.72,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1438.46,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1418.2,,,percent of total billed charges,,,,,,1215.6,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2026,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,911.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,1316.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HEAD DEP HIP COBALT CHROME 28   8,25483,CDM,0278,RC,,,,,,outpatient,facility,,,2026,2026,129.72,2026,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1722.1,,,percent of total billed charges,,,,,,607.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,384.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,384.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1519.5,,,percent of total billed charges,,,,,,1418.2,,,percent of total billed charges,,,,,,1418.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1316.9,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2026,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1418.2,,,percent of total billed charges,,,,,,1114.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,1413.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1438.46,,,percent of total billed charges,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1418.2,,,percent of total billed charges,,,,,,1215.6,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1722.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2026,,,percent of total billed charges,,,,,,911.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1519.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2026,,,fee schedule,,,,,,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,2026,,,percent of total billed charges,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1114.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2026,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1722.1,,,percent of total billed charges,,,,,,1519.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH IX GUIDE VB JCL4.5 8FR .088 X 100,25503,CDM,0272,RC,,,,,,inpatient,facility,,,129.5,129.5,58.27,129.5,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,90.65,,,percent of total billed charges,,,,,,77.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,
CATH IX GUIDE VB JCL4.5 8FR .088 X 100,25503,CDM,0272,RC,,,,,,outpatient,facility,,,129.5,129.5,24.61,1016,,84.17,,,percent of total billed charges,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,38.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,24.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,97.12,,,percent of total billed charges,,,,,,90.65,,,percent of total billed charges,,,,,,90.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,84.17,,,percent of total billed charges,,,,,,31.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",87.41,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,129.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.39,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",90.65,,,percent of total billed charges,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,90.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,91.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,90.65,,,percent of total billed charges,,,,,,77.7,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,110.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,55.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.12,,,percent of total billed charges,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,129.5,,,percent of total billed charges,,,,,,58.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.5,,,fee schedule,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,129.5,,,percent of total billed charges,,,,,,62.16,,,percent of total billed charges,,,,,,,,,,,,,,,76.41,,,percent of total billed charges,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,129.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,110.08,,,percent of total billed charges,,,,,,97.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T LOCK 5.0 X 75,25585,CDM,0278,RC,,,,,,inpatient,facility,,,177.9,177.9,80.06,177.9,,,,,,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,133.43,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.54,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",126.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,,106.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,80.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,115.64,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T LOCK 5.0 X 75,25585,CDM,0278,RC,,,,,,outpatient,facility,,,177.9,177.9,33.8,177.9,,115.64,,,percent of total billed charges,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,53.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,97.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,97.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133.42,,,percent of total billed charges,,,,,,124.53,,,percent of total billed charges,,,,,,124.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,115.64,,,percent of total billed charges,,,,,,42.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,177.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.72,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",124.53,,,percent of total billed charges,,,,,,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,124.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,126.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,124.53,,,percent of total billed charges,,,,,,106.74,,,percent of total billed charges,,,,,,80.06,,,percent of total billed charges,,,,,,,,,,,,,,,151.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,177.9,,,percent of total billed charges,,,,,,76.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.43,,,percent of total billed charges,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,177.9,,,percent of total billed charges,,,,,,80.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,,fee schedule,,,,,,177.9,,,percent of total billed charges,,,,,,177.9,,,percent of total billed charges,,,,,,177.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,177.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.22,,,percent of total billed charges,,,,,,133.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC TC99M DTPA SN UP TO 30 MCI,25597605,CDM,0255,RC,,,,,,inpatient,facility,,,331.76,331.76,149.29,331.76,,,,,,,,,,,,,,,,,,,,282,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.23,,,percent of total billed charges,,,,,,199.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,331.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282,,,percent of total billed charges,,,,,,,,,,,,,,
HC TC99M DTPA SN UP TO 30 MCI,25597605,CDM,0255,RC,,,,,,outpatient,facility,,,331.76,331.76,63.03,1016,,215.64,,,percent of total billed charges,,,,,,,,,,,,,,,282,,,percent of total billed charges,,,,,,99.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,155.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,63.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,248.82,,,percent of total billed charges,,,,,,232.23,,,percent of total billed charges,,,,,,232.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,215.64,,,percent of total billed charges,,,,,,79.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,331.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.34,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",232.23,,,percent of total billed charges,,,,,,,,,,,,,,,331.76,,,percent of total billed charges,,,,,,231.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,235.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,232.23,,,percent of total billed charges,,,,,,199.06,,,percent of total billed charges,,,,,,149.29,,,percent of total billed charges,,,,,,,,,,,,,,,282,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.76,,,percent of total billed charges,,,,,,331.76,,,percent of total billed charges,,,,,,142.66,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,331.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,331.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.82,,,percent of total billed charges,,,,,,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,331.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,331.76,,,percent of total billed charges,,,,,,149.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.76,,,fee schedule,,,,,,331.76,,,percent of total billed charges,,,,,,331.76,,,percent of total billed charges,,,,,,331.76,,,percent of total billed charges,,,,,,159.24,,,percent of total billed charges,,,,,,,,,,,,,,,195.74,,,percent of total billed charges,,,,,,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,331.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,282,,,percent of total billed charges,,,,,,248.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LSCP LAPSAC SURG TISSUE POUCH  i,25671,CDM,0272,RC,,,,,,inpatient,facility,,,265.42,265.42,119.44,265.42,,,,,,,,,,,,,,,,,,,,225.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,185.79,,,percent of total billed charges,,,,,,159.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,225.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,119.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,225.61,,,percent of total billed charges,,,,,,,,,,,,,,
LSCP LAPSAC SURG TISSUE POUCH  i,25671,CDM,0272,RC,,,,,,outpatient,facility,,,265.42,265.42,50.43,1016,,172.52,,,percent of total billed charges,,,,,,,,,,,,,,,225.61,,,percent of total billed charges,,,,,,79.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,50.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,50.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,199.07,,,percent of total billed charges,,,,,,185.79,,,percent of total billed charges,,,,,,185.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,172.52,,,percent of total billed charges,,,,,,63.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.16,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,265.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,111.48,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",185.79,,,percent of total billed charges,,,,,,,,,,,,,,,265.42,,,percent of total billed charges,,,,,,185.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,185.79,,,percent of total billed charges,,,,,,159.25,,,percent of total billed charges,,,,,,119.44,,,percent of total billed charges,,,,,,,,,,,,,,,225.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.42,,,percent of total billed charges,,,,,,265.42,,,percent of total billed charges,,,,,,114.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,265.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,265.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.06,,,percent of total billed charges,,,,,,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,265.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,265.42,,,percent of total billed charges,,,,,,119.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.42,,,fee schedule,,,,,,265.42,,,percent of total billed charges,,,,,,265.42,,,percent of total billed charges,,,,,,265.42,,,percent of total billed charges,,,,,,127.4,,,percent of total billed charges,,,,,,,,,,,,,,,156.6,,,percent of total billed charges,,,,,,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,265.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,225.61,,,percent of total billed charges,,,,,,199.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SYN FEM CANN TI STRL 14 X 400,25765,CDM,0278,RC,,,,,,inpatient,facility,,,2765.92,2765.92,1244.66,2765.92,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2351.03,,,percent of total billed charges,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2212.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2074.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1521.26,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1672,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1963.8,,,percent of total billed charges,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1936.14,,,percent of total billed charges,,,,,,1659.55,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2351.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2765.92,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2074.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2765.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1244.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2351.03,,,percent of total billed charges,,,,,,1797.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SYN FEM CANN TI STRL 14 X 400,25765,CDM,0278,RC,,,,,,outpatient,facility,,,2765.92,2765.92,129.72,2765.92,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2351.03,,,percent of total billed charges,,,,,,829.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,525.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,525.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2074.44,,,percent of total billed charges,,,,,,1936.14,,,percent of total billed charges,,,,,,1936.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1797.85,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2765.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1936.14,,,percent of total billed charges,,,,,,1521.26,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,,percent of total billed charges,,,,,,1929.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1963.8,,,percent of total billed charges,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1936.14,,,percent of total billed charges,,,,,,1659.55,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2351.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,,percent of total billed charges,,,,,,2765.92,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2765.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2074.44,,,percent of total billed charges,,,,,,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2765.92,,,percent of total billed charges,,,,,,1244.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2074.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2765.92,,,fee schedule,,,,,,2765.92,,,percent of total billed charges,,,,,,2765.92,,,percent of total billed charges,,,,,,2765.92,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2351.03,,,percent of total billed charges,,,,,,2074.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BOLT SYN LOCK FEM TI 4.9X30,25769,CDM,0278,RC,,,,,,inpatient,facility,,,352.44,352.44,158.6,352.44,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.95,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,264.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,229.09,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BOLT SYN LOCK FEM TI 4.9X30,25769,CDM,0278,RC,,,,,,outpatient,facility,,,352.44,352.44,66.96,352.44,,229.09,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,105.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264.33,,,percent of total billed charges,,,,,,246.71,,,percent of total billed charges,,,,,,246.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,229.09,,,percent of total billed charges,,,,,,84.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,352.44,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",246.71,,,percent of total billed charges,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,245.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,151.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,fee schedule,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,299.57,,,percent of total billed charges,,,,,,264.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BOLT SYN LOCK FEM TI 4.9X32,25770,CDM,0278,RC,,,,,,inpatient,facility,,,352.44,352.44,158.6,352.44,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.95,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,264.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,229.09,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BOLT SYN LOCK FEM TI 4.9X32,25770,CDM,0278,RC,,,,,,outpatient,facility,,,352.44,352.44,66.96,352.44,,229.09,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,105.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264.33,,,percent of total billed charges,,,,,,246.71,,,percent of total billed charges,,,,,,246.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,229.09,,,percent of total billed charges,,,,,,84.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,352.44,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",246.71,,,percent of total billed charges,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,245.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,151.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,fee schedule,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,299.57,,,percent of total billed charges,,,,,,264.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BOLT SYN LOCK FEM TI 4.9X38,25773,CDM,0278,RC,,,,,,inpatient,facility,,,352.44,352.44,158.6,352.44,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.95,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,264.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,229.09,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BOLT SYN LOCK FEM TI 4.9X38,25773,CDM,0278,RC,,,,,,outpatient,facility,,,352.44,352.44,66.96,352.44,,229.09,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,105.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264.33,,,percent of total billed charges,,,,,,246.71,,,percent of total billed charges,,,,,,246.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,229.09,,,percent of total billed charges,,,,,,84.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,352.44,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",246.71,,,percent of total billed charges,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,245.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,151.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,fee schedule,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,299.57,,,percent of total billed charges,,,,,,264.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BOLT SYN LOCK FEM TI 4.9X40,25774,CDM,0278,RC,,,,,,inpatient,facility,,,352.44,352.44,158.6,352.44,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.95,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,264.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,229.09,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BOLT SYN LOCK FEM TI 4.9X40,25774,CDM,0278,RC,,,,,,outpatient,facility,,,352.44,352.44,66.96,352.44,,229.09,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,105.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264.33,,,percent of total billed charges,,,,,,246.71,,,percent of total billed charges,,,,,,246.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,229.09,,,percent of total billed charges,,,,,,84.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,352.44,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",246.71,,,percent of total billed charges,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,245.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,151.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,fee schedule,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,299.57,,,percent of total billed charges,,,,,,264.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BOLT SYN LOCK FEM TI 4.9X50,25779,CDM,0278,RC,,,,,,inpatient,facility,,,331.1,331.1,149,331.1,,,,,,,,,,,,,,,,,,,,281.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.88,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,248.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.15,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",235.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,231.77,,,percent of total billed charges,,,,,,198.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,281.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,331.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,149,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.44,,,percent of total billed charges,,,,,,215.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BOLT SYN LOCK FEM TI 4.9X50,25779,CDM,0278,RC,,,,,,outpatient,facility,,,331.1,331.1,62.91,331.1,,215.22,,,percent of total billed charges,,,,,,,,,,,,,,,281.44,,,percent of total billed charges,,,,,,99.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,155.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,62.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,182.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,248.32,,,percent of total billed charges,,,,,,231.77,,,percent of total billed charges,,,,,,231.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,215.22,,,percent of total billed charges,,,,,,79.46,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,331.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,139.06,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",231.77,,,percent of total billed charges,,,,,,,,,,,,,,,331.1,,,percent of total billed charges,,,,,,230.94,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,235.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,231.77,,,percent of total billed charges,,,,,,198.66,,,percent of total billed charges,,,,,,149,,,percent of total billed charges,,,,,,,,,,,,,,,281.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.1,,,percent of total billed charges,,,,,,331.1,,,percent of total billed charges,,,,,,142.37,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,331.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,331.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.32,,,percent of total billed charges,,,,,,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,331.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,331.1,,,percent of total billed charges,,,,,,149,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.1,,,fee schedule,,,,,,331.1,,,percent of total billed charges,,,,,,331.1,,,percent of total billed charges,,,,,,331.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,331.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,281.44,,,percent of total billed charges,,,,,,248.32,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD BIF 16 X 8 X 40  c,2578,CDM,0278,RC,,,,,,inpatient,facility,,,1513.08,1513.08,680.89,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1210.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1134.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,914.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,983.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD BIF 16 X 8 X 40  c,2578,CDM,0278,RC,,,,,,outpatient,facility,,,1513.08,1513.08,129.72,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,453.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1134.81,,,percent of total billed charges,,,,,,1059.16,,,percent of total billed charges,,,,,,1059.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,983.5,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1513.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1055.37,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,,percent of total billed charges,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1513.08,,,fee schedule,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1286.12,,,percent of total billed charges,,,,,,1134.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BOLT SYN LOCK FEM TI 4.9X54,25781,CDM,0278,RC,,,,,,inpatient,facility,,,352.44,352.44,158.6,352.44,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.95,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,264.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,229.09,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BOLT SYN LOCK FEM TI 4.9X54,25781,CDM,0278,RC,,,,,,outpatient,facility,,,352.44,352.44,66.96,352.44,,229.09,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,105.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264.33,,,percent of total billed charges,,,,,,246.71,,,percent of total billed charges,,,,,,246.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,229.09,,,percent of total billed charges,,,,,,84.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,352.44,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",246.71,,,percent of total billed charges,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,245.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,151.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,fee schedule,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,299.57,,,percent of total billed charges,,,,,,264.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BOLT SYN LOCK FEM TI 4.9X64,25785,CDM,0278,RC,,,,,,inpatient,facility,,,352.44,352.44,158.6,352.44,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.95,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,264.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,229.09,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BOLT SYN LOCK FEM TI 4.9X64,25785,CDM,0278,RC,,,,,,outpatient,facility,,,352.44,352.44,66.96,352.44,,229.09,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,105.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,193.84,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,264.33,,,percent of total billed charges,,,,,,246.71,,,percent of total billed charges,,,,,,246.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,229.09,,,percent of total billed charges,,,,,,84.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,352.44,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",246.71,,,percent of total billed charges,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,245.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,250.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,246.71,,,percent of total billed charges,,,,,,211.46,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,299.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,151.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,352.44,,,percent of total billed charges,,,,,,158.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,,fee schedule,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,352.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,352.44,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,299.57,,,percent of total billed charges,,,,,,264.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD BIF 18 X 9 X 40  c,2579,CDM,0278,RC,,,,,,inpatient,facility,,,1513.08,1513.08,680.89,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1210.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1134.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,914.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,983.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD BIF 18 X 9 X 40  c,2579,CDM,0278,RC,,,,,,outpatient,facility,,,1513.08,1513.08,129.72,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,453.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1134.81,,,percent of total billed charges,,,,,,1059.16,,,percent of total billed charges,,,,,,1059.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,983.5,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1513.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1055.37,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,,percent of total billed charges,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1513.08,,,fee schedule,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1286.12,,,percent of total billed charges,,,,,,1134.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC 3 FLUTE CALIB 4.0 X 270,25797,CDM,0272,RC,,,,,,inpatient,facility,,,865.37,865.37,389.42,865.37,,,,,,,,,,,,,,,,,,,,735.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,649.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,614.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,605.76,,,percent of total billed charges,,,,,,519.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,735.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,865.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,649.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,865.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,389.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,735.56,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC 3 FLUTE CALIB 4.0 X 270,25797,CDM,0272,RC,,,,,,outpatient,facility,,,865.37,865.37,129.72,1016,,562.49,,,percent of total billed charges,,,,,,,,,,,,,,,735.56,,,percent of total billed charges,,,,,,259.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,406.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,164.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,164.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,649.02,,,percent of total billed charges,,,,,,605.76,,,percent of total billed charges,,,,,,605.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,562.49,,,percent of total billed charges,,,,,,207.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",584.12,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,865.37,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,363.46,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",605.76,,,percent of total billed charges,,,,,,,,,,,,,,,865.37,,,percent of total billed charges,,,,,,603.6,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,614.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,605.76,,,percent of total billed charges,,,,,,519.22,,,percent of total billed charges,,,,,,389.42,,,percent of total billed charges,,,,,,,,,,,,,,,735.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,865.37,,,percent of total billed charges,,,,,,865.37,,,percent of total billed charges,,,,,,372.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,865.37,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,865.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,649.03,,,percent of total billed charges,,,,,,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,865.37,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,865.37,,,percent of total billed charges,,,,,,389.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,649.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,865.37,,,fee schedule,,,,,,865.37,,,percent of total billed charges,,,,,,865.37,,,percent of total billed charges,,,,,,865.37,,,percent of total billed charges,,,,,,415.38,,,percent of total billed charges,,,,,,,,,,,,,,,510.57,,,percent of total billed charges,,,,,,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,865.37,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,735.56,,,percent of total billed charges,,,,,,649.03,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN 3 FLUTE BRAD PT 4.0 X 150,25798,CDM,0272,RC,,,,,,inpatient,facility,,,912.03,912.03,410.41,912.03,,,,,,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,638.42,,,percent of total billed charges,,,,,,547.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,410.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN 3 FLUTE BRAD PT 4.0 X 150,25798,CDM,0272,RC,,,,,,outpatient,facility,,,912.03,912.03,129.72,1016,,592.82,,,percent of total billed charges,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,273.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,428.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,173.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,173.29,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,684.02,,,percent of total billed charges,,,,,,638.42,,,percent of total billed charges,,,,,,638.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,592.82,,,percent of total billed charges,,,,,,218.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",615.62,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,912.03,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,383.05,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",638.42,,,percent of total billed charges,,,,,,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,636.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,647.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,638.42,,,percent of total billed charges,,,,,,547.22,,,percent of total billed charges,,,,,,410.41,,,percent of total billed charges,,,,,,,,,,,,,,,775.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,912.03,,,percent of total billed charges,,,,,,392.17,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,912.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.02,,,percent of total billed charges,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,912.03,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,912.03,,,percent of total billed charges,,,,,,410.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,912.03,,,fee schedule,,,,,,912.03,,,percent of total billed charges,,,,,,912.03,,,percent of total billed charges,,,,,,912.03,,,percent of total billed charges,,,,,,437.77,,,percent of total billed charges,,,,,,,,,,,,,,,538.1,,,percent of total billed charges,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,912.03,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,775.23,,,percent of total billed charges,,,,,,684.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
TUBE SYN CHANGE INTRAMEDULARY,25801,CDM,0272,RC,,,,,,inpatient,facility,,,357.42,357.42,160.84,357.42,,,,,,,,,,,,,,,,,,,,303.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,232.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,250.19,,,percent of total billed charges,,,,,,214.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,303.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,357.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,160.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.81,,,percent of total billed charges,,,,,,,,,,,,,,
TUBE SYN CHANGE INTRAMEDULARY,25801,CDM,0272,RC,,,,,,outpatient,facility,,,357.42,357.42,67.91,1016,,232.32,,,percent of total billed charges,,,,,,,,,,,,,,,303.81,,,percent of total billed charges,,,,,,107.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,167.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,67.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,268.07,,,percent of total billed charges,,,,,,250.19,,,percent of total billed charges,,,,,,250.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,232.32,,,percent of total billed charges,,,,,,85.78,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",241.26,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,357.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.12,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",250.19,,,percent of total billed charges,,,,,,,,,,,,,,,357.42,,,percent of total billed charges,,,,,,249.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,253.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,250.19,,,percent of total billed charges,,,,,,214.45,,,percent of total billed charges,,,,,,160.84,,,percent of total billed charges,,,,,,,,,,,,,,,303.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.42,,,percent of total billed charges,,,,,,357.42,,,percent of total billed charges,,,,,,153.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,357.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,357.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.06,,,percent of total billed charges,,,,,,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,357.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,357.42,,,percent of total billed charges,,,,,,160.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.42,,,fee schedule,,,,,,357.42,,,percent of total billed charges,,,,,,357.42,,,percent of total billed charges,,,,,,357.42,,,percent of total billed charges,,,,,,171.56,,,percent of total billed charges,,,,,,,,,,,,,,,210.88,,,percent of total billed charges,,,,,,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,357.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,303.81,,,percent of total billed charges,,,,,,268.06,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SHELL STR HIP SECUR FIT ACET XTRA 58MM,25804,CDM,0278,RC,,,,,,inpatient,facility,,,4035.9,4035.9,1816.15,4035.9,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,3430.52,,,percent of total billed charges,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3228.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3026.93,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2219.75,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2439.7,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2865.49,,,percent of total billed charges,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2825.13,,,percent of total billed charges,,,,,,2421.54,,,percent of total billed charges,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3430.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2219.75,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4035.9,,,percent of total billed charges,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3026.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4035.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1816.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3430.52,,,percent of total billed charges,,,,,,2623.34,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SHELL STR HIP SECUR FIT ACET XTRA 58MM,25804,CDM,0278,RC,,,,,,outpatient,facility,,,4035.9,4035.9,129.72,4035.9,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3430.52,,,percent of total billed charges,,,,,,1210.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,766.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,766.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3026.92,,,percent of total billed charges,,,,,,2825.13,,,percent of total billed charges,,,,,,2825.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2623.34,,,percent of total billed charges,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4035.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2825.13,,,percent of total billed charges,,,,,,2219.75,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4035.9,,,percent of total billed charges,,,,,,2815.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2865.49,,,percent of total billed charges,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2825.13,,,percent of total billed charges,,,,,,2421.54,,,percent of total billed charges,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3430.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2219.75,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4035.9,,,percent of total billed charges,,,,,,4035.9,,,percent of total billed charges,,,,,,2219.75,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4035.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4035.9,,,percent of total billed charges,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3026.92,,,percent of total billed charges,,,,,,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4035.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4035.9,,,percent of total billed charges,,,,,,1816.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3026.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4035.9,,,fee schedule,,,,,,4035.9,,,percent of total billed charges,,,,,,4035.9,,,percent of total billed charges,,,,,,4035.9,,,percent of total billed charges,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2219.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4035.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3430.52,,,percent of total billed charges,,,,,,3026.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH EP STEERABLE LIVEWIRE DUO DECA SUPER LNG CURL,25809,CDM,0272,RC,,,,,,inpatient,facility,,,3437,3437,1546.65,3437,,,,,,,,,,,,,,,,,,,,2921.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2577.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2234.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2440.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2405.9,,,percent of total billed charges,,,,,,2062.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2921.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3437,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2577.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3437,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1546.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2921.45,,,percent of total billed charges,,,,,,,,,,,,,,
CATH EP STEERABLE LIVEWIRE DUO DECA SUPER LNG CURL,25809,CDM,0272,RC,,,,,,outpatient,facility,,,3437,3437,129.72,3437,,2234.05,,,percent of total billed charges,,,,,,,,,,,,,,,2921.45,,,percent of total billed charges,,,,,,1031.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1615.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,653.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,653.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2577.74,,,percent of total billed charges,,,,,,2405.9,,,percent of total billed charges,,,,,,2405.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2234.05,,,percent of total billed charges,,,,,,824.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2319.97,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3437,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1443.54,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2405.9,,,percent of total billed charges,,,,,,,,,,,,,,,3437,,,percent of total billed charges,,,,,,2397.31,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2440.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2405.9,,,percent of total billed charges,,,,,,2062.2,,,percent of total billed charges,,,,,,1546.65,,,percent of total billed charges,,,,,,,,,,,,,,,2921.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3437,,,percent of total billed charges,,,,,,3437,,,percent of total billed charges,,,,,,1477.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,3437,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3437,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2577.75,,,percent of total billed charges,,,,,,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3437,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3437,,,percent of total billed charges,,,,,,1546.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2577.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3437,,,fee schedule,,,,,,3437,,,percent of total billed charges,,,,,,3437,,,percent of total billed charges,,,,,,3437,,,percent of total billed charges,,,,,,1649.76,,,percent of total billed charges,,,,,,,,,,,,,,,2027.83,,,percent of total billed charges,,,,,,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3437,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2921.45,,,percent of total billed charges,,,,,,2577.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT WLG VASC GORTEX TW STRTCH 6 X 40  c,2581,CDM,0278,RC,,,,,,inpatient,facility,,,1354,1354,609.3,1354,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1150.9,,,percent of total billed charges,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1083.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1015.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,744.7,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,818.49,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",961.34,,,percent of total billed charges,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,947.8,,,percent of total billed charges,,,,,,812.4,,,percent of total billed charges,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1150.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,744.7,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1354,,,percent of total billed charges,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1015.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1354,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,609.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1150.9,,,percent of total billed charges,,,,,,880.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT WLG VASC GORTEX TW STRTCH 6 X 40  c,2581,CDM,0278,RC,,,,,,outpatient,facility,,,1354,1354,129.72,1354,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1150.9,,,percent of total billed charges,,,,,,406.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,257.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,257.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1015.5,,,percent of total billed charges,,,,,,947.8,,,percent of total billed charges,,,,,,947.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,880.1,,,percent of total billed charges,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1354,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,947.8,,,percent of total billed charges,,,,,,744.7,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1354,,,percent of total billed charges,,,,,,944.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,961.34,,,percent of total billed charges,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,947.8,,,percent of total billed charges,,,,,,812.4,,,percent of total billed charges,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1150.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,744.7,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1354,,,percent of total billed charges,,,,,,1354,,,percent of total billed charges,,,,,,744.7,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1354,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1354,,,percent of total billed charges,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1015.5,,,percent of total billed charges,,,,,,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1354,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1354,,,percent of total billed charges,,,,,,609.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1015.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1354,,,fee schedule,,,,,,1354,,,percent of total billed charges,,,,,,1354,,,percent of total billed charges,,,,,,1354,,,percent of total billed charges,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,744.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1354,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1150.9,,,percent of total billed charges,,,,,,1015.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 10percent 500CC 2B0163Q,25810056,CDM,0258,RC,,,,,,inpatient,facility,,,131.56,131.56,59.2,131.56,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 10percent 500CC 2B0163Q,25810056,CDM,0258,RC,,,,,,outpatient,facility,,,131.56,131.56,25,1016,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,39.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,98.67,,,percent of total billed charges,,,,,,92.09,,,percent of total billed charges,,,,,,92.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,31.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,131.56,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",92.09,,,percent of total billed charges,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,91.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,56.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,fee schedule,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,63.15,,,percent of total billed charges,,,,,,,,,,,,,,,77.62,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,111.83,,,percent of total billed charges,,,,,,98.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent NACL .9percent INJ 2B1063Q,25810192,CDM,0258,RC,,,,,,inpatient,facility,,,131.56,131.56,59.2,131.56,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent NACL .9percent INJ 2B1063Q,25810192,CDM,0258,RC,,,,,,outpatient,facility,,,131.56,131.56,25,1016,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,39.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,98.67,,,percent of total billed charges,,,,,,92.09,,,percent of total billed charges,,,,,,92.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,31.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,131.56,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",92.09,,,percent of total billed charges,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,91.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,56.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,fee schedule,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,63.15,,,percent of total billed charges,,,,,,,,,,,,,,,77.62,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,111.83,,,percent of total billed charges,,,,,,98.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent NACL .45percent INJ 2B1073Q,25810608,CDM,0258,RC,,,,,,inpatient,facility,,,134.42,134.42,60.49,134.42,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.09,,,percent of total billed charges,,,,,,80.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent NACL .45percent INJ 2B1073Q,25810608,CDM,0258,RC,,,,,,outpatient,facility,,,134.42,134.42,25.54,1016,,87.37,,,percent of total billed charges,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,40.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.81,,,percent of total billed charges,,,,,,94.09,,,percent of total billed charges,,,,,,94.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,87.37,,,percent of total billed charges,,,,,,32.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,134.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.46,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",94.09,,,percent of total billed charges,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,93.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,95.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.09,,,percent of total billed charges,,,,,,80.65,,,percent of total billed charges,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,57.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.82,,,percent of total billed charges,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,,percent of total billed charges,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,fee schedule,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,64.52,,,percent of total billed charges,,,,,,,,,,,,,,,79.31,,,percent of total billed charges,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,114.26,,,percent of total billed charges,,,,,,100.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL NACL 0.9percent 50ML 2B1306,25810613,CDM,0258,RC,,,,,,inpatient,facility,,,72.02,72.02,32.41,72.02,,,,,,,,,,,,,,,,,,,,61.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,50.41,,,percent of total billed charges,,,,,,43.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,72.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,32.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.22,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL NACL 0.9percent 50ML 2B1306,25810613,CDM,0258,RC,,,,,,outpatient,facility,,,72.02,72.02,13.68,1016,,46.81,,,percent of total billed charges,,,,,,,,,,,,,,,61.22,,,percent of total billed charges,,,,,,21.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,13.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,54.01,,,percent of total billed charges,,,,,,50.41,,,percent of total billed charges,,,,,,50.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,46.81,,,percent of total billed charges,,,,,,17.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,72.02,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,30.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",50.41,,,percent of total billed charges,,,,,,,,,,,,,,,72.02,,,percent of total billed charges,,,,,,50.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,51.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,50.41,,,percent of total billed charges,,,,,,43.21,,,percent of total billed charges,,,,,,32.41,,,percent of total billed charges,,,,,,,,,,,,,,,61.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.02,,,percent of total billed charges,,,,,,72.02,,,percent of total billed charges,,,,,,30.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,72.02,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,72.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.02,,,percent of total billed charges,,,,,,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,72.02,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,72.02,,,percent of total billed charges,,,,,,32.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.02,,,fee schedule,,,,,,72.02,,,percent of total billed charges,,,,,,72.02,,,percent of total billed charges,,,,,,72.02,,,percent of total billed charges,,,,,,34.57,,,percent of total billed charges,,,,,,,,,,,,,,,42.49,,,percent of total billed charges,,,,,,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,72.02,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.22,,,percent of total billed charges,,,,,,54.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL NACL 0.9percent 100ML 2B1307,25810614,CDM,0258,RC,,,,,,inpatient,facility,,,74.88,74.88,33.7,74.88,,,,,,,,,,,,,,,,,,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.42,,,percent of total billed charges,,,,,,44.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,74.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,33.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL NACL 0.9percent 100ML 2B1307,25810614,CDM,0258,RC,,,,,,outpatient,facility,,,74.88,74.88,14.23,1016,,48.67,,,percent of total billed charges,,,,,,,,,,,,,,,63.65,,,percent of total billed charges,,,,,,22.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.23,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,56.16,,,percent of total billed charges,,,,,,52.42,,,percent of total billed charges,,,,,,52.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,48.67,,,percent of total billed charges,,,,,,17.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,74.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,31.45,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",52.42,,,percent of total billed charges,,,,,,,,,,,,,,,74.88,,,percent of total billed charges,,,,,,52.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,53.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.42,,,percent of total billed charges,,,,,,44.93,,,percent of total billed charges,,,,,,33.7,,,percent of total billed charges,,,,,,,,,,,,,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.88,,,percent of total billed charges,,,,,,74.88,,,percent of total billed charges,,,,,,32.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,74.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,74.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.16,,,percent of total billed charges,,,,,,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.88,,,percent of total billed charges,,,,,,33.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.88,,,fee schedule,,,,,,74.88,,,percent of total billed charges,,,,,,74.88,,,percent of total billed charges,,,,,,74.88,,,percent of total billed charges,,,,,,35.94,,,percent of total billed charges,,,,,,,,,,,,,,,44.18,,,percent of total billed charges,,,,,,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,74.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,63.65,,,percent of total billed charges,,,,,,56.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL NACL INJ 0.9percent 150CC 2B1321,25810619,CDM,0258,RC,,,,,,inpatient,facility,,,87.36,87.36,39.31,87.36,,,,,,,,,,,,,,,,,,,,74.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,52.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,74.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.26,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL NACL INJ 0.9percent 150CC 2B1321,25810619,CDM,0258,RC,,,,,,outpatient,facility,,,87.36,87.36,16.6,1016,,56.78,,,percent of total billed charges,,,,,,,,,,,,,,,74.26,,,percent of total billed charges,,,,,,26.21,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,16.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,16.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,65.52,,,percent of total billed charges,,,,,,61.15,,,percent of total billed charges,,,,,,61.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,56.78,,,percent of total billed charges,,,,,,20.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,87.36,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.69,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.15,,,percent of total billed charges,,,,,,,,,,,,,,,87.36,,,percent of total billed charges,,,,,,60.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,62.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,61.15,,,percent of total billed charges,,,,,,52.42,,,percent of total billed charges,,,,,,39.31,,,percent of total billed charges,,,,,,,,,,,,,,,74.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.36,,,percent of total billed charges,,,,,,87.36,,,percent of total billed charges,,,,,,37.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,87.36,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.52,,,percent of total billed charges,,,,,,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.36,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,87.36,,,percent of total billed charges,,,,,,39.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.36,,,fee schedule,,,,,,87.36,,,percent of total billed charges,,,,,,87.36,,,percent of total billed charges,,,,,,87.36,,,percent of total billed charges,,,,,,41.93,,,percent of total billed charges,,,,,,,,,,,,,,,51.54,,,percent of total billed charges,,,,,,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,87.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.26,,,percent of total billed charges,,,,,,65.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL NACL INJ 0.9percent250ML 2B1322Q,25810620,CDM,0258,RC,,,,,,inpatient,facility,,,90.22,90.22,40.6,90.22,,,,,,,,,,,,,,,,,,,,76.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.15,,,percent of total billed charges,,,,,,54.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,76.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,90.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.69,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL NACL INJ 0.9percent250ML 2B1322Q,25810620,CDM,0258,RC,,,,,,outpatient,facility,,,90.22,90.22,17.14,1016,,58.64,,,percent of total billed charges,,,,,,,,,,,,,,,76.69,,,percent of total billed charges,,,,,,27.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,42.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,17.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,67.67,,,percent of total billed charges,,,,,,63.15,,,percent of total billed charges,,,,,,63.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,58.64,,,percent of total billed charges,,,,,,21.65,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,90.22,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,37.89,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",63.15,,,percent of total billed charges,,,,,,,,,,,,,,,90.22,,,percent of total billed charges,,,,,,62.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,64.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.15,,,percent of total billed charges,,,,,,54.13,,,percent of total billed charges,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,76.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.22,,,percent of total billed charges,,,,,,90.22,,,percent of total billed charges,,,,,,38.79,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,90.22,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,90.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.66,,,percent of total billed charges,,,,,,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,90.22,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,90.22,,,percent of total billed charges,,,,,,40.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.22,,,fee schedule,,,,,,90.22,,,percent of total billed charges,,,,,,90.22,,,percent of total billed charges,,,,,,90.22,,,percent of total billed charges,,,,,,43.31,,,percent of total billed charges,,,,,,,,,,,,,,,53.23,,,percent of total billed charges,,,,,,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,90.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,76.69,,,percent of total billed charges,,,,,,67.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 10percent IN WATER 1000ML 2B0164,25812181,CDM,0258,RC,,,,,,inpatient,facility,,,131.56,131.56,59.2,131.56,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 10percent IN WATER 1000ML 2B0164,25812181,CDM,0258,RC,,,,,,outpatient,facility,,,131.56,131.56,25,1016,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,39.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,98.67,,,percent of total billed charges,,,,,,92.09,,,percent of total billed charges,,,,,,92.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,31.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,131.56,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",92.09,,,percent of total billed charges,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,91.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,56.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,fee schedule,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,63.15,,,percent of total billed charges,,,,,,,,,,,,,,,77.62,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,111.83,,,percent of total billed charges,,,,,,98.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent and .33percent NACL 500 2B1083,25812762,CDM,0258,RC,,,,,,inpatient,facility,,,131.56,131.56,59.2,131.56,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent and .33percent NACL 500 2B1083,25812762,CDM,0258,RC,,,,,,outpatient,facility,,,131.56,131.56,25,1016,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,39.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,98.67,,,percent of total billed charges,,,,,,92.09,,,percent of total billed charges,,,,,,92.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,31.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,131.56,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",92.09,,,percent of total billed charges,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,91.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,56.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,fee schedule,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,63.15,,,percent of total billed charges,,,,,,,,,,,,,,,77.62,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,111.83,,,percent of total billed charges,,,,,,98.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN CALCANEAL SS 60MM,25839,CDM,0278,RC,,,,,,inpatient,facility,,,2014.98,2014.98,906.74,2014.98,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1712.73,,,percent of total billed charges,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1611.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1511.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1108.24,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1218.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1430.64,,,percent of total billed charges,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1410.49,,,percent of total billed charges,,,,,,1208.99,,,percent of total billed charges,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1712.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.24,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2014.98,,,percent of total billed charges,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1511.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2014.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,906.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1712.73,,,percent of total billed charges,,,,,,1309.74,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN CALCANEAL SS 60MM,25839,CDM,0278,RC,,,,,,outpatient,facility,,,2014.98,2014.98,129.72,2014.98,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1712.73,,,percent of total billed charges,,,,,,604.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,382.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,382.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1511.23,,,percent of total billed charges,,,,,,1410.49,,,percent of total billed charges,,,,,,1410.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1309.74,,,percent of total billed charges,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2014.98,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1410.49,,,percent of total billed charges,,,,,,1108.24,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2014.98,,,percent of total billed charges,,,,,,1405.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1430.64,,,percent of total billed charges,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1410.49,,,percent of total billed charges,,,,,,1208.99,,,percent of total billed charges,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1712.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1108.24,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2014.98,,,percent of total billed charges,,,,,,2014.98,,,percent of total billed charges,,,,,,1108.24,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2014.98,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2014.98,,,percent of total billed charges,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1511.24,,,percent of total billed charges,,,,,,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2014.98,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2014.98,,,percent of total billed charges,,,,,,906.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1511.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2014.98,,,fee schedule,,,,,,2014.98,,,percent of total billed charges,,,,,,2014.98,,,percent of total billed charges,,,,,,2014.98,,,percent of total billed charges,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1108.24,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2014.98,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1712.73,,,percent of total billed charges,,,,,,1511.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PORT DUAL SLIM LO PROF W ATTACH OPEN END CATH 7.0F,25880,CDM,0278,RC,,,,,,inpatient,facility,,,850,850,382.5,850,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,637.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,513.83,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,552.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PORT DUAL SLIM LO PROF W ATTACH OPEN END CATH 7.0F,25880,CDM,0278,RC,,,,,,outpatient,facility,,,850,850,129.72,850,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,255,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637.5,,,percent of total billed charges,,,,,,595,,,percent of total billed charges,,,,,,595,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,850,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,592.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,850,,,fee schedule,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,722.5,,,percent of total billed charges,,,,,,637.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent INJ 250ML 2B0062Q,25890276,CDM,0258,RC,,,,,,inpatient,facility,,,93.08,93.08,41.89,93.08,,,,,,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.16,,,percent of total billed charges,,,,,,55.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,41.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent INJ 250ML 2B0062Q,25890276,CDM,0258,RC,,,,,,outpatient,facility,,,93.08,93.08,17.69,1016,,60.5,,,percent of total billed charges,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,27.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,17.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,69.81,,,percent of total billed charges,,,,,,65.16,,,percent of total billed charges,,,,,,65.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,60.5,,,percent of total billed charges,,,,,,22.34,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,93.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.09,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",65.16,,,percent of total billed charges,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,64.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,66.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.16,,,percent of total billed charges,,,,,,55.85,,,percent of total billed charges,,,,,,41.89,,,percent of total billed charges,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,93.08,,,percent of total billed charges,,,,,,40.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,93.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.81,,,percent of total billed charges,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.08,,,percent of total billed charges,,,,,,41.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,fee schedule,,,,,,93.08,,,percent of total billed charges,,,,,,93.08,,,percent of total billed charges,,,,,,93.08,,,percent of total billed charges,,,,,,44.68,,,percent of total billed charges,,,,,,,,,,,,,,,54.92,,,percent of total billed charges,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,79.12,,,percent of total billed charges,,,,,,69.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent INJ 500ML 2B0063Q,25890277,CDM,0258,RC,,,,,,inpatient,facility,,,141.18,141.18,63.53,141.18,,,,,,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98.83,,,percent of total billed charges,,,,,,84.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent INJ 500ML 2B0063Q,25890277,CDM,0258,RC,,,,,,outpatient,facility,,,141.18,141.18,26.82,1016,,91.77,,,percent of total billed charges,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,42.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,26.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,105.89,,,percent of total billed charges,,,,,,98.83,,,percent of total billed charges,,,,,,98.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,91.77,,,percent of total billed charges,,,,,,33.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,141.18,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,59.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",98.83,,,percent of total billed charges,,,,,,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,98.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98.83,,,percent of total billed charges,,,,,,84.71,,,percent of total billed charges,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,141.18,,,percent of total billed charges,,,,,,60.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,141.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.88,,,percent of total billed charges,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.18,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,141.18,,,percent of total billed charges,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,,fee schedule,,,,,,141.18,,,percent of total billed charges,,,,,,141.18,,,percent of total billed charges,,,,,,141.18,,,percent of total billed charges,,,,,,67.77,,,percent of total billed charges,,,,,,,,,,,,,,,83.3,,,percent of total billed charges,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,120,,,percent of total billed charges,,,,,,105.89,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent INJ 1000ML 2B0064,25890278,CDM,0258,RC,,,,,,inpatient,facility,,,137.28,137.28,61.78,137.28,,,,,,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,96.1,,,percent of total billed charges,,,,,,82.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,61.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent INJ 1000ML 2B0064,25890278,CDM,0258,RC,,,,,,outpatient,facility,,,137.28,137.28,26.08,1016,,89.23,,,percent of total billed charges,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,41.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,64.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,26.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,102.96,,,percent of total billed charges,,,,,,96.1,,,percent of total billed charges,,,,,,96.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,89.23,,,percent of total billed charges,,,,,,32.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,137.28,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,57.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",96.1,,,percent of total billed charges,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,95.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,97.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,96.1,,,percent of total billed charges,,,,,,82.37,,,percent of total billed charges,,,,,,61.78,,,percent of total billed charges,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,137.28,,,percent of total billed charges,,,,,,59.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,137.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,137.28,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,137.28,,,percent of total billed charges,,,,,,61.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,fee schedule,,,,,,137.28,,,percent of total billed charges,,,,,,137.28,,,percent of total billed charges,,,,,,137.28,,,percent of total billed charges,,,,,,65.89,,,percent of total billed charges,,,,,,,,,,,,,,,81,,,percent of total billed charges,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.69,,,percent of total billed charges,,,,,,102.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX INJ 5percent 250ML,25890282,CDM,0258,RC,,,,,,inpatient,facility,,,93.08,93.08,41.89,93.08,,,,,,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.16,,,percent of total billed charges,,,,,,55.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,41.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX INJ 5percent 250ML,25890282,CDM,0258,RC,,,,,,outpatient,facility,,,93.08,93.08,17.69,1016,,60.5,,,percent of total billed charges,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,27.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,17.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.69,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,69.81,,,percent of total billed charges,,,,,,65.16,,,percent of total billed charges,,,,,,65.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,60.5,,,percent of total billed charges,,,,,,22.34,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,93.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.09,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",65.16,,,percent of total billed charges,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,64.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,66.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,65.16,,,percent of total billed charges,,,,,,55.85,,,percent of total billed charges,,,,,,41.89,,,percent of total billed charges,,,,,,,,,,,,,,,79.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,93.08,,,percent of total billed charges,,,,,,40.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,93.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.81,,,percent of total billed charges,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,93.08,,,percent of total billed charges,,,,,,41.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.08,,,fee schedule,,,,,,93.08,,,percent of total billed charges,,,,,,93.08,,,percent of total billed charges,,,,,,93.08,,,percent of total billed charges,,,,,,44.68,,,percent of total billed charges,,,,,,,,,,,,,,,54.92,,,percent of total billed charges,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,93.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,79.12,,,percent of total billed charges,,,,,,69.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent and .45percent NACL 1000ML,25890283,CDM,0258,RC,,,,,,inpatient,facility,,,142.48,142.48,64.12,142.48,,,,,,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,99.74,,,percent of total billed charges,,,,,,85.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,64.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent and .45percent NACL 1000ML,25890283,CDM,0258,RC,,,,,,outpatient,facility,,,142.48,142.48,27.07,1016,,92.61,,,percent of total billed charges,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,42.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,27.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,27.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,106.86,,,percent of total billed charges,,,,,,99.74,,,percent of total billed charges,,,,,,99.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,92.61,,,percent of total billed charges,,,,,,34.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,142.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,59.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",99.74,,,percent of total billed charges,,,,,,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,99.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,101.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,99.74,,,percent of total billed charges,,,,,,85.49,,,percent of total billed charges,,,,,,64.12,,,percent of total billed charges,,,,,,,,,,,,,,,121.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,142.48,,,percent of total billed charges,,,,,,61.27,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,142.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,142.48,,,percent of total billed charges,,,,,,64.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.48,,,fee schedule,,,,,,142.48,,,percent of total billed charges,,,,,,142.48,,,percent of total billed charges,,,,,,142.48,,,percent of total billed charges,,,,,,68.39,,,percent of total billed charges,,,,,,,,,,,,,,,84.06,,,percent of total billed charges,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,142.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,121.11,,,percent of total billed charges,,,,,,106.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent and .9percent NACL 1000ML,25890285,CDM,0258,RC,,,,,,inpatient,facility,,,131.56,131.56,59.2,131.56,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent and .9percent NACL 1000ML,25890285,CDM,0258,RC,,,,,,outpatient,facility,,,131.56,131.56,25,1016,,85.51,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,39.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,61.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,98.67,,,percent of total billed charges,,,,,,92.09,,,percent of total billed charges,,,,,,92.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,85.51,,,percent of total billed charges,,,,,,31.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,131.56,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",92.09,,,percent of total billed charges,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,91.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,93.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,92.09,,,percent of total billed charges,,,,,,78.94,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,111.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,56.57,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,131.56,,,percent of total billed charges,,,,,,59.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.56,,,fee schedule,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,131.56,,,percent of total billed charges,,,,,,63.15,,,percent of total billed charges,,,,,,,,,,,,,,,77.62,,,percent of total billed charges,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,131.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,111.83,,,percent of total billed charges,,,,,,98.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL RINGER LACT 1000ML 2B2324,25890288,CDM,0258,RC,,,,,,inpatient,facility,,,134.42,134.42,60.49,134.42,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.09,,,percent of total billed charges,,,,,,80.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL RINGER LACT 1000ML 2B2324,25890288,CDM,0258,RC,,,,,,outpatient,facility,,,134.42,134.42,25.54,1016,,87.37,,,percent of total billed charges,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,40.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.81,,,percent of total billed charges,,,,,,94.09,,,percent of total billed charges,,,,,,94.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,87.37,,,percent of total billed charges,,,,,,32.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,134.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.46,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",94.09,,,percent of total billed charges,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,93.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,95.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.09,,,percent of total billed charges,,,,,,80.65,,,percent of total billed charges,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,57.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.82,,,percent of total billed charges,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,,percent of total billed charges,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,fee schedule,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,64.52,,,percent of total billed charges,,,,,,,,,,,,,,,79.31,,,percent of total billed charges,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,114.26,,,percent of total billed charges,,,,,,100.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL PLASMA LYT INJ PH7.4 1000M,25890289,CDM,0258,RC,,,,,,inpatient,facility,,,121.94,121.94,54.87,121.94,,,,,,,,,,,,,,,,,,,,103.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,85.36,,,percent of total billed charges,,,,,,73.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,103.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,121.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,54.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.65,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL PLASMA LYT INJ PH7.4 1000M,25890289,CDM,0258,RC,,,,,,outpatient,facility,,,121.94,121.94,23.17,1016,,79.26,,,percent of total billed charges,,,,,,,,,,,,,,,103.65,,,percent of total billed charges,,,,,,36.58,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,57.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,23.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,23.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,91.46,,,percent of total billed charges,,,,,,85.36,,,percent of total billed charges,,,,,,85.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,79.26,,,percent of total billed charges,,,,,,29.27,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,121.94,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,51.21,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",85.36,,,percent of total billed charges,,,,,,,,,,,,,,,121.94,,,percent of total billed charges,,,,,,85.05,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,86.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,85.36,,,percent of total billed charges,,,,,,73.16,,,percent of total billed charges,,,,,,54.87,,,percent of total billed charges,,,,,,,,,,,,,,,103.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.94,,,percent of total billed charges,,,,,,121.94,,,percent of total billed charges,,,,,,52.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,121.94,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,121.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.46,,,percent of total billed charges,,,,,,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,121.94,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,121.94,,,percent of total billed charges,,,,,,54.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.94,,,fee schedule,,,,,,121.94,,,percent of total billed charges,,,,,,121.94,,,percent of total billed charges,,,,,,121.94,,,percent of total billed charges,,,,,,58.53,,,percent of total billed charges,,,,,,,,,,,,,,,71.94,,,percent of total billed charges,,,,,,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,121.94,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.65,,,percent of total billed charges,,,,,,91.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent RINGER LACT 1000 2B2074,25890290,CDM,0258,RC,,,,,,inpatient,facility,,,141.18,141.18,63.53,141.18,,,,,,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98.83,,,percent of total billed charges,,,,,,84.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent RINGER LACT 1000 2B2074,25890290,CDM,0258,RC,,,,,,outpatient,facility,,,141.18,141.18,26.82,1016,,91.77,,,percent of total billed charges,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,42.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,26.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,105.89,,,percent of total billed charges,,,,,,98.83,,,percent of total billed charges,,,,,,98.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,91.77,,,percent of total billed charges,,,,,,33.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,141.18,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,59.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",98.83,,,percent of total billed charges,,,,,,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,98.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,100.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98.83,,,percent of total billed charges,,,,,,84.71,,,percent of total billed charges,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,120,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,141.18,,,percent of total billed charges,,,,,,60.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,141.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.88,,,percent of total billed charges,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.18,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,141.18,,,percent of total billed charges,,,,,,63.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.18,,,fee schedule,,,,,,141.18,,,percent of total billed charges,,,,,,141.18,,,percent of total billed charges,,,,,,141.18,,,percent of total billed charges,,,,,,67.77,,,percent of total billed charges,,,,,,,,,,,,,,,83.3,,,percent of total billed charges,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,141.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,120,,,percent of total billed charges,,,,,,105.89,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL NACL INJ.45percent 1000ML 2B1314,25890293,CDM,0258,RC,,,,,,inpatient,facility,,,137.28,137.28,61.78,137.28,,,,,,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,96.1,,,percent of total billed charges,,,,,,82.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,61.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL NACL INJ.45percent 1000ML 2B1314,25890293,CDM,0258,RC,,,,,,outpatient,facility,,,137.28,137.28,26.08,1016,,89.23,,,percent of total billed charges,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,41.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,64.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,26.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,102.96,,,percent of total billed charges,,,,,,96.1,,,percent of total billed charges,,,,,,96.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,89.23,,,percent of total billed charges,,,,,,32.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,137.28,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,57.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",96.1,,,percent of total billed charges,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,95.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,97.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,96.1,,,percent of total billed charges,,,,,,82.37,,,percent of total billed charges,,,,,,61.78,,,percent of total billed charges,,,,,,,,,,,,,,,116.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,137.28,,,percent of total billed charges,,,,,,59.03,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,137.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,137.28,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,137.28,,,percent of total billed charges,,,,,,61.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.28,,,fee schedule,,,,,,137.28,,,percent of total billed charges,,,,,,137.28,,,percent of total billed charges,,,,,,137.28,,,percent of total billed charges,,,,,,65.89,,,percent of total billed charges,,,,,,,,,,,,,,,81,,,percent of total billed charges,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,137.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,116.69,,,percent of total billed charges,,,,,,102.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL NACL INJ 0.9percent500ML 2B1323Q,25890295,CDM,0258,RC,,,,,,inpatient,facility,,,134.42,134.42,60.49,134.42,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.09,,,percent of total billed charges,,,,,,80.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL NACL INJ 0.9percent500ML 2B1323Q,25890295,CDM,0258,RC,,,,,,outpatient,facility,,,134.42,134.42,25.54,1016,,87.37,,,percent of total billed charges,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,40.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,63.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,100.81,,,percent of total billed charges,,,,,,94.09,,,percent of total billed charges,,,,,,94.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,87.37,,,percent of total billed charges,,,,,,32.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,134.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,56.46,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",94.09,,,percent of total billed charges,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,93.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,95.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,94.09,,,percent of total billed charges,,,,,,80.65,,,percent of total billed charges,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,114.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,57.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.82,,,percent of total billed charges,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,134.42,,,percent of total billed charges,,,,,,60.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.42,,,fee schedule,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,134.42,,,percent of total billed charges,,,,,,64.52,,,percent of total billed charges,,,,,,,,,,,,,,,79.31,,,percent of total billed charges,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,134.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,114.26,,,percent of total billed charges,,,,,,100.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOL NACL INJ 0.9percent 1000M 2B1324,25890297,CDM,0258,RC,,,,,,inpatient,facility,,,39,39,17.55,39,,,,,,,,,,,,,,,,,,,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,27.3,,,percent of total billed charges,,,,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,17.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOL NACL INJ 0.9percent 1000M 2B1324,25890297,CDM,0258,RC,,,,,,outpatient,facility,,,39,39,7.41,1016,,25.35,,,percent of total billed charges,,,,,,,,,,,,,,,33.15,,,percent of total billed charges,,,,,,11.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,7.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,29.25,,,percent of total billed charges,,,,,,27.3,,,percent of total billed charges,,,,,,27.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,25.35,,,percent of total billed charges,,,,,,9.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,39,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.38,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",27.3,,,percent of total billed charges,,,,,,,,,,,,,,,39,,,percent of total billed charges,,,,,,27.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,27.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,27.3,,,percent of total billed charges,,,,,,23.4,,,percent of total billed charges,,,,,,17.55,,,percent of total billed charges,,,,,,,,,,,,,,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39,,,percent of total billed charges,,,,,,39,,,percent of total billed charges,,,,,,16.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,39,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.25,,,percent of total billed charges,,,,,,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,39,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,39,,,percent of total billed charges,,,,,,17.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39,,,fee schedule,,,,,,39,,,percent of total billed charges,,,,,,39,,,percent of total billed charges,,,,,,39,,,percent of total billed charges,,,,,,18.72,,,percent of total billed charges,,,,,,,,,,,,,,,23.01,,,percent of total billed charges,,,,,,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,33.15,,,percent of total billed charges,,,,,,29.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SOD CHLOR INJ 10 ML,25891214,CDM,0258,RC,,,,,,inpatient,facility,,,7.28,7.28,3.28,7.28,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,
HC SOD CHLOR INJ 10 ML,25891214,CDM,0258,RC,,,,,,outpatient,facility,,,7.28,7.28,1.38,1016,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,5.46,,,percent of total billed charges,,,,,,5.1,,,percent of total billed charges,,,,,,5.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,,,,1.75,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,3.49,1.75,7.7,280,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",,,,,,,,,,,,,,,,,,,7.28,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.06,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,5.3,2.92,12.06,281,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",5.1,,,percent of total billed charges,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,5.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,4.37,,,percent of total billed charges,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,7.28,,,percent of total billed charges,,,,,,3.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,3.49,1.75,7.7,278,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,,,,,,,,,service not payable,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.28,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,7.28,,,percent of total billed charges,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,fee schedule,,,,,,7.28,,,percent of total billed charges,,,,,,7.28,,,percent of total billed charges,,,,,,7.28,,,percent of total billed charges,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.19,,,percent of total billed charges,,,,,,5.46,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC HEPARIN FLUSH INJ 10U,25891215,CDM,0250,RC,J1642,HCPCS,,,,inpatient,facility,,,7.28,7.28,3.28,7.28,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,
HC HEPARIN FLUSH INJ 10U,25891215,CDM,0250,RC,J1642,HCPCS,,,,outpatient,facility,,,7.28,7.28,0.02,1016,,4.73,,,percent of total billed charges,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,2.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,3.42,,,percent of total billed charges,,,,,,4.91,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1,,,fee schedule,,,,,,5.1,,,percent of total billed charges,,,,,,5.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4.73,,,percent of total billed charges,,,,,,1.75,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.91,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7.28,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,3.06,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",5.1,,,percent of total billed charges,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,5.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,5.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.1,,,percent of total billed charges,,,,,,4.37,,,percent of total billed charges,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,6.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,7.28,,,percent of total billed charges,,,,,,3.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,7.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,0.02,,,fee schedule,,,,,,,,,,,,,,service not payable,0.02,,,case rate,,,,,,,,,,,,,,service not payable,,,,,,,,,service not payable,7.28,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,service not payable,0.02,,,case rate,,,,,,,,,,,,,,service not payable,7.28,,,percent of total billed charges,,,,,,3.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.28,,,fee schedule,,,,,,7.28,,,percent of total billed charges,,,,,,7.28,,,percent of total billed charges,,,,,,7.28,,,percent of total billed charges,,,,,,3.49,,,percent of total billed charges,,,,,,,,,,,,,,,4.3,,,percent of total billed charges,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,7.28,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.19,,,percent of total billed charges,,,,,,5.46,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV D5W 50ML,25892000,CDM,0258,RC,,,,,,inpatient,facility,,,46.8,46.8,21.06,46.8,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV D5W 50ML,25892000,CDM,0258,RC,,,,,,outpatient,facility,,,46.8,46.8,8.89,1016,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,14.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.1,,,percent of total billed charges,,,,,,32.76,,,percent of total billed charges,,,,,,32.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,11.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,46.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.76,,,percent of total billed charges,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,32.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,20.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,fee schedule,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.78,,,percent of total billed charges,,,,,,35.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV D5W 100ML,25892001,CDM,0258,RC,,,,,,inpatient,facility,,,46.8,46.8,21.06,46.8,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV D5W 100ML,25892001,CDM,0258,RC,,,,,,outpatient,facility,,,46.8,46.8,8.89,1016,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,14.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.1,,,percent of total billed charges,,,,,,32.76,,,percent of total billed charges,,,,,,32.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,11.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,46.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.76,,,percent of total billed charges,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,32.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,20.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,fee schedule,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.78,,,percent of total billed charges,,,,,,35.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV D5W 250ML,25892002,CDM,0258,RC,,,,,,inpatient,facility,,,46.8,46.8,21.06,46.8,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV D5W 250ML,25892002,CDM,0258,RC,,,,,,outpatient,facility,,,46.8,46.8,8.89,1016,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,14.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.1,,,percent of total billed charges,,,,,,32.76,,,percent of total billed charges,,,,,,32.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,11.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,46.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.76,,,percent of total billed charges,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,32.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,20.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,fee schedule,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.78,,,percent of total billed charges,,,,,,35.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV NS 50ML,25892005,CDM,0258,RC,,,,,,inpatient,facility,,,46.8,46.8,21.06,46.8,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV NS 50ML,25892005,CDM,0258,RC,,,,,,outpatient,facility,,,46.8,46.8,8.89,1016,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,14.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.1,,,percent of total billed charges,,,,,,32.76,,,percent of total billed charges,,,,,,32.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,11.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,46.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.76,,,percent of total billed charges,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,32.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,20.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,fee schedule,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.78,,,percent of total billed charges,,,,,,35.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV NS 100ML,25892006,CDM,0258,RC,,,,,,inpatient,facility,,,46.8,46.8,21.06,46.8,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV NS 100ML,25892006,CDM,0258,RC,,,,,,outpatient,facility,,,46.8,46.8,8.89,1016,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,14.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.1,,,percent of total billed charges,,,,,,32.76,,,percent of total billed charges,,,,,,32.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,11.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,46.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.76,,,percent of total billed charges,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,32.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,20.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,fee schedule,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.78,,,percent of total billed charges,,,,,,35.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV NS 150ML,25892007,CDM,0258,RC,,,,,,inpatient,facility,,,46.8,46.8,21.06,46.8,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV NS 150ML,25892007,CDM,0258,RC,,,,,,outpatient,facility,,,46.8,46.8,8.89,1016,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,14.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.1,,,percent of total billed charges,,,,,,32.76,,,percent of total billed charges,,,,,,32.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,11.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,46.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.76,,,percent of total billed charges,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,32.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,20.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,fee schedule,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.78,,,percent of total billed charges,,,,,,35.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV D5 0.45NS 250ML,25892019,CDM,0258,RC,,,,,,inpatient,facility,,,46.8,46.8,21.06,46.8,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV D5 0.45NS 250ML,25892019,CDM,0258,RC,,,,,,outpatient,facility,,,46.8,46.8,8.89,1016,,30.42,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,14.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,8.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,35.1,,,percent of total billed charges,,,,,,32.76,,,percent of total billed charges,,,,,,32.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,30.42,,,percent of total billed charges,,,,,,11.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,46.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",32.76,,,percent of total billed charges,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,32.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.76,,,percent of total billed charges,,,,,,28.08,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,39.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,20.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,46.8,,,percent of total billed charges,,,,,,21.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.8,,,fee schedule,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,22.46,,,percent of total billed charges,,,,,,,,,,,,,,,27.61,,,percent of total billed charges,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,46.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,39.78,,,percent of total billed charges,,,,,,35.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent INJ 50ML 2B0086,25899947,CDM,0258,RC,,,,,,inpatient,facility,,,76.18,76.18,34.28,76.18,,,,,,,,,,,,,,,,,,,,64.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,53.33,,,percent of total billed charges,,,,,,45.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,64.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,34.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.75,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent INJ 50ML 2B0086,25899947,CDM,0258,RC,,,,,,outpatient,facility,,,76.18,76.18,14.47,1016,,49.52,,,percent of total billed charges,,,,,,,,,,,,,,,64.75,,,percent of total billed charges,,,,,,22.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,57.13,,,percent of total billed charges,,,,,,53.33,,,percent of total billed charges,,,,,,53.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,49.52,,,percent of total billed charges,,,,,,18.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,76.18,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,32,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",53.33,,,percent of total billed charges,,,,,,,,,,,,,,,76.18,,,percent of total billed charges,,,,,,53.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,54.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,53.33,,,percent of total billed charges,,,,,,45.71,,,percent of total billed charges,,,,,,34.28,,,percent of total billed charges,,,,,,,,,,,,,,,64.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.18,,,percent of total billed charges,,,,,,76.18,,,percent of total billed charges,,,,,,32.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,76.18,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,76.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.14,,,percent of total billed charges,,,,,,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,76.18,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.18,,,percent of total billed charges,,,,,,34.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.18,,,fee schedule,,,,,,76.18,,,percent of total billed charges,,,,,,76.18,,,percent of total billed charges,,,,,,76.18,,,percent of total billed charges,,,,,,36.57,,,percent of total billed charges,,,,,,,,,,,,,,,44.95,,,percent of total billed charges,,,,,,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,76.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,64.75,,,percent of total billed charges,,,,,,57.14,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DEX 5percent INJ 100ML 2B0087,25899950,CDM,0258,RC,,,,,,inpatient,facility,,,79.04,79.04,35.57,79.04,,,,,,,,,,,,,,,,,,,,67.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,55.33,,,percent of total billed charges,,,,,,47.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,67.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,35.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.18,,,percent of total billed charges,,,,,,,,,,,,,,
HC DEX 5percent INJ 100ML 2B0087,25899950,CDM,0258,RC,,,,,,outpatient,facility,,,79.04,79.04,15.02,1016,,51.38,,,percent of total billed charges,,,,,,,,,,,,,,,67.18,,,percent of total billed charges,,,,,,23.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,37.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,15.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,15.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,59.28,,,percent of total billed charges,,,,,,55.33,,,percent of total billed charges,,,,,,55.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,51.38,,,percent of total billed charges,,,,,,18.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,79.04,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,33.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",55.33,,,percent of total billed charges,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,55.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,56.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,55.33,,,percent of total billed charges,,,,,,47.42,,,percent of total billed charges,,,,,,35.57,,,percent of total billed charges,,,,,,,,,,,,,,,67.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,79.04,,,percent of total billed charges,,,,,,33.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,79.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.28,,,percent of total billed charges,,,,,,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,79.04,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,79.04,,,percent of total billed charges,,,,,,35.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.04,,,fee schedule,,,,,,79.04,,,percent of total billed charges,,,,,,79.04,,,percent of total billed charges,,,,,,79.04,,,percent of total billed charges,,,,,,37.94,,,percent of total billed charges,,,,,,,,,,,,,,,46.63,,,percent of total billed charges,,,,,,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,79.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,67.18,,,percent of total billed charges,,,,,,59.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BOLT DEP FEM PFC SIGMA STEM,25900,CDM,0278,RC,,,,,,inpatient,facility,,,252,252,113.4,252,,,,,,,,,,,,,,,,,,,,214.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,201.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,189,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.33,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",178.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,176.4,,,percent of total billed charges,,,,,,151.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,214.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,252,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,113.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.2,,,percent of total billed charges,,,,,,163.8,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
BOLT DEP FEM PFC SIGMA STEM,25900,CDM,0278,RC,,,,,,outpatient,facility,,,252,252,47.88,252,,163.8,,,percent of total billed charges,,,,,,,,,,,,,,,214.2,,,percent of total billed charges,,,,,,75.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,118.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,47.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,47.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,138.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,138.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,138.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,189,,,percent of total billed charges,,,,,,176.4,,,percent of total billed charges,,,,,,176.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,163.8,,,percent of total billed charges,,,,,,60.48,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,252,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,105.84,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",176.4,,,percent of total billed charges,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,175.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,178.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,176.4,,,percent of total billed charges,,,,,,151.2,,,percent of total billed charges,,,,,,113.4,,,percent of total billed charges,,,,,,,,,,,,,,,214.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,108.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,252,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189,,,percent of total billed charges,,,,,,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,252,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,252,,,percent of total billed charges,,,,,,113.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252,,,fee schedule,,,,,,252,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,252,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,214.2,,,percent of total billed charges,,,,,,189,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEAD MED CAPSUREFIX NOVUS 58CM 5076,25941,CDM,0275,RC,,,,,,inpatient,facility,,,850,850,382.5,850,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,
LEAD MED CAPSUREFIX NOVUS 58CM 5076,25941,CDM,0275,RC,,,,,,outpatient,facility,,,850,850,129.72,850,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,255,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637.5,,,percent of total billed charges,,,,,,595,,,percent of total billed charges,,,,,,595,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,850,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,592.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,850,,,fee schedule,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,722.5,,,percent of total billed charges,,,,,,637.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC LUBRICANT LIDOCAINE 10ML STERL,25995016,CDM,0259,RC,,,,,,inpatient,facility,,,26.78,26.78,12.05,26.78,,,,,,,,,,,,,,,,,,,,22.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,18.75,,,percent of total billed charges,,,,,,16.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,22.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,26.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,12.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.76,,,percent of total billed charges,,,,,,,,,,,,,,
HC LUBRICANT LIDOCAINE 10ML STERL,25995016,CDM,0259,RC,,,,,,outpatient,facility,,,26.78,26.78,5.09,1016,,17.41,,,percent of total billed charges,,,,,,,,,,,,,,,22.76,,,percent of total billed charges,,,,,,8.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,20.09,,,percent of total billed charges,,,,,,18.75,,,percent of total billed charges,,,,,,18.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,17.41,,,percent of total billed charges,,,,,,6.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,26.78,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,11.25,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",18.75,,,percent of total billed charges,,,,,,,,,,,,,,,26.78,,,percent of total billed charges,,,,,,18.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,19.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,18.75,,,percent of total billed charges,,,,,,16.07,,,percent of total billed charges,,,,,,13.39,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,22.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.78,,,percent of total billed charges,,,,,,26.78,,,percent of total billed charges,,,,,,11.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,26.78,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,26.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.08,,,percent of total billed charges,,,,,,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,26.78,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,26.78,,,percent of total billed charges,,,,,,12.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.78,,,fee schedule,,,,,,26.78,,,percent of total billed charges,,,,,,26.78,,,percent of total billed charges,,,,,,26.78,,,percent of total billed charges,,,,,,12.85,,,percent of total billed charges,,,,,,,,,,,,,,,15.8,,,percent of total billed charges,,,,,,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,26.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.76,,,percent of total billed charges,,,,,,20.09,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC INTRAVENOUS INFUSIONPEMIVIBARTFOR THE PRE EXPOS,26000224,CDM,0260,RC,M0224,HCPCS,,,,inpatient,facility,,,1126.25,1126.25,506.81,1126.25,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,799.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,788.38,,,percent of total billed charges,,,,,,675.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,
HC INTRAVENOUS INFUSIONPEMIVIBARTFOR THE PRE EXPOS,26000224,CDM,0260,RC,M0224,HCPCS,,,,outpatient,facility,,,1126.25,1126.25,129.72,1126.25,,732.06,,,percent of total billed charges,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,529.34,,,percent of total billed charges,,,,,,760.22,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,754.59,,,percent of total billed charges,,,,,,855.95,,,percent of total billed charges,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,822.16,,,percent of total billed charges,,,,,,844.69,,,percent of total billed charges,,,,,,788.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.06,,,percent of total billed charges,,,,,,270.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",760.22,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1126.25,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,473.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",788.38,,,percent of total billed charges,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,785.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,799.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,788.38,,,percent of total billed charges,,,,,,675.75,,,percent of total billed charges,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,484.29,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,,percent of total billed charges,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.47,,,fee schedule,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,957.31,,,percent of total billed charges,,,,,,844.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC INTRAVENOUS INFUSIONPEMIVIBARTFOR THE PRE EXPOS,26000224,CDM,0260,RC,M0224,HCPCS,01506,APC,,outpatient,facility,,,1126.25,1126.25,391.4,1151.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,575.59,,,fee schedule,,,,,,1061.96,,,fee schedule,,,,,,1114.34,,,fee schedule,,,,,,699.91,,,fee schedule,,,,,,453.1,,,fee schedule,,,,,,990.01,,,fee schedule,,,,,,,,,,,,,,,460.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,460.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,552.56,,,fee schedule,,,,,,469.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.47,,,fee schedule,,,,,,460.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,460.47,,,fee schedule,,,,,,,,,,,,,,,690.71,,,fee schedule,,,,,,460.47,,,fee schedule,,,,,,414.42,,,fee schedule,,,,,,460.47,,,fee schedule,,,,,,1151.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.7,,,fee schedule,,,,,,485.31,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",460.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.1,,,fee schedule,,,,,,460.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,460.47,,,fee schedule,,,,,,805.82,,,fee schedule,,,,,,453.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.59,,,fee schedule,,,,,,,,,,,,,,,575.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,414.42,,,fee schedule,,,,,,,,,,,,,,,460.47,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.1,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC INTRAVENOUS INFUSIONPEMIVIBARTFOR THE PRE EXPOS,26000224,CDM,0260,RC,M0224,HCPCS,111,EAPG,,outpatient,facility,,,1126.25,1126.25,175.54,196.6,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.09,,,fee schedule,,,,,,,,,,,,,,,184.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,196.6,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH DIAG IV INFINIT,26076200,CDM,0260,RC,96365,CPT,,,,inpatient,facility,,,840,840,378,840,,,,,,,,,,,,,,,,,,,,714,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,546,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,596.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,588,,,percent of total billed charges,,,,,,504,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,714,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,840,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,840,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,378,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,714,,,percent of total billed charges,,,,,,,,,,,,,,
HC THER PROPH DIAG IV INFINIT,26076200,CDM,0260,RC,96365,CPT,,,,outpatient,facility,,,840,840,58.29,840,,546,,,percent of total billed charges,,,,,,,,,,,,,,,714,,,percent of total billed charges,,,,,,,,,,,,,,,394.8,,,percent of total billed charges,,,,,,305.33,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,554.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,562.8,,,percent of total billed charges,,,,,,638.4,,,percent of total billed charges,,,,,,840,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,613.2,,,percent of total billed charges,,,,,,630,,,percent of total billed charges,,,,,,588,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,546,,,percent of total billed charges,,,,,,201.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",305.33,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,840,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,352.8,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,352.8,280.08,366.52,45,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",588,,,percent of total billed charges,,,,,,,,,,,,,,,840,,,percent of total billed charges,,,,,,311.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,596.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,588,,,percent of total billed charges,,,,,,504,,,percent of total billed charges,,,,,,378,,,percent of total billed charges,,,,,,,,,,,,,,,714,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,840,,,percent of total billed charges,,,,,,840,,,percent of total billed charges,,,,,,361.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,840,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,840,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,840,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630,,,percent of total billed charges,,,,,,64.82,,,fee schedule,,,,,,,,,,,,,,service not payable,58.56,,,case rate,,,,,,,,,,,,,,service not payable,59.26,,,fee schedule,,,,,,58.29,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,59.26,,,case rate,,,,,,,,,,,,,,service not payable,58.56,,,case rate,,,,,,,,,,,,,,service not payable,840,,,percent of total billed charges,,,,,,378,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,840,,,percent of total billed charges,,,,,,840,,,percent of total billed charges,,,,,,840,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,840,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,840,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,840,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,714,,,percent of total billed charges,,,,,,335.01,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC THER PROPH DIAG IV INFINIT,26076200,CDM,0260,RC,96365,CPT,05693,APC,,outpatient,facility,,,840,840,188.8,555.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,216.29,203.8,218.35,50,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,512.26,,,fee schedule,,,,,,537.53,,,fee schedule,,,,,,337.62,,,fee schedule,,,,,,218.57,,,fee schedule,,,,,,477.56,,,fee schedule,,,,,,,,,,,,,,,222.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,208.11,208.11,218.57,1 through 10,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,222.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,208.11,194.15,208.11,18,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,266.54,,,fee schedule,,,,,,226.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,333.18,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,199.91,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,555.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.67,,,fee schedule,,,,,,234.1,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,209.98,207.95,222.9,1 through 10,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.57,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,388.71,,,fee schedule,,,,,,218.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,199.91,,,fee schedule,,,,,,,,,,,,,,,222.12,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH DIAG IV INFINIT,26076200,CDM,0260,RC,96365,CPT,111,EAPG,,outpatient,facility,,,840,840,175.54,196.6,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.09,,,fee schedule,,,,,,,,,,,,,,,184.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,196.6,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH DG IV INFADD ON,26076201,CDM,0260,RC,96366,CPT,,,,inpatient,facility,,,312.34,312.34,140.55,312.34,,,,,,,,,,,,,,,,,,,,265.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.64,,,percent of total billed charges,,,,,,187.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,265.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,312.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,140.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.49,,,percent of total billed charges,,,,,,,,,,,,,,
HC THER PROPH DG IV INFADD ON,26076201,CDM,0260,RC,96366,CPT,,,,outpatient,facility,,,312.34,312.34,15.79,312.34,,203.02,,,percent of total billed charges,,,,,,,,,,,,,,,265.49,,,percent of total billed charges,,,,,,,,,,,,,,,146.8,,,percent of total billed charges,,,,,,118.52,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.27,,,percent of total billed charges,,,,,,237.38,,,percent of total billed charges,,,,,,312.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,228.01,,,percent of total billed charges,,,,,,234.26,,,percent of total billed charges,,,,,,218.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,203.02,,,percent of total billed charges,,,,,,74.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.52,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,312.34,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.18,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,262.37,127.51,655.91,27,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",218.64,,,percent of total billed charges,,,,,,,,,,,,,,,312.34,,,percent of total billed charges,,,,,,120.94,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,221.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.64,,,percent of total billed charges,,,,,,187.4,,,percent of total billed charges,,,,,,140.55,,,percent of total billed charges,,,,,,,,,,,,,,,265.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.34,,,percent of total billed charges,,,,,,312.34,,,percent of total billed charges,,,,,,134.31,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,312.34,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,312.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.26,,,percent of total billed charges,,,,,,18.58,,,fee schedule,,,,,,,,,,,,,,service not payable,15.79,,,case rate,,,,,,,,,,,,,,service not payable,15.96,,,fee schedule,,,,,,17.89,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,15.96,,,case rate,,,,,,,,,,,,,,service not payable,15.79,,,case rate,,,,,,,,,,,,,,service not payable,312.34,,,percent of total billed charges,,,,,,140.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,312.34,,,percent of total billed charges,,,,,,312.34,,,percent of total billed charges,,,,,,312.34,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,312.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,312.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,312.34,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,265.49,,,percent of total billed charges,,,,,,130.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC THER PROPH DG IV INFADD ON,26076201,CDM,0260,RC,96366,CPT,05691,APC,,outpatient,facility,,,312.34,312.34,41.56,122.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,47.2,44.57,95.39,25,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,112.78,,,fee schedule,,,,,,118.34,,,fee schedule,,,,,,74.33,,,fee schedule,,,,,,48.12,,,fee schedule,,,,,,105.13,,,fee schedule,,,,,,,,,,,,,,,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,45.57,45.57,91.14,1 through 10,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,91.14,86.06,182.28,13,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,58.68,,,fee schedule,,,,,,49.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,73.35,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,44.01,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,122.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.32,,,fee schedule,,,,,,51.54,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.12,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,85.58,,,fee schedule,,,,,,48.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,44.01,,,fee schedule,,,,,,,,,,,,,,,48.9,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH DG IV INFADD ON,26076201,CDM,0260,RC,96366,CPT,110,EAPG,,outpatient,facility,,,312.34,312.34,323.32,362.12,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.65,,,fee schedule,,,,,,,,,,,,,,,339.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,362.12,,,fee schedule,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC INFUSION HYDRATION INIT 31M 1H,26076202,CDM,0260,RC,96360,CPT,,,,inpatient,facility,,,734,734,330.3,734,,,,,,,,,,,,,,,,,,,,623.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,521.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,513.8,,,percent of total billed charges,,,,,,440.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,623.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,734,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,734,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,330.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,623.9,,,percent of total billed charges,,,,,,,,,,,,,,
HC INFUSION HYDRATION INIT 31M 1H,26076202,CDM,0260,RC,96360,CPT,,,,outpatient,facility,,,734,734,29.38,734,,477.1,,,percent of total billed charges,,,,,,,,,,,,,,,623.9,,,percent of total billed charges,,,,,,,,,,,,,,,344.98,,,percent of total billed charges,,,,,,263.15,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,484.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,491.78,,,percent of total billed charges,,,,,,557.84,,,percent of total billed charges,,,,,,734,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,535.82,,,percent of total billed charges,,,,,,550.5,,,percent of total billed charges,,,,,,513.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,477.1,,,percent of total billed charges,,,,,,176.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",263.15,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,734,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,308.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,308.28,110.92,308.28,22,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",513.8,,,percent of total billed charges,,,,,,,,,,,,,,,734,,,percent of total billed charges,,,,,,268.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,521.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,513.8,,,percent of total billed charges,,,,,,440.4,,,percent of total billed charges,,,,,,330.3,,,percent of total billed charges,,,,,,,,,,,,,,,623.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,734,,,percent of total billed charges,,,,,,734,,,percent of total billed charges,,,,,,315.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,734,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,734,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,734,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.5,,,percent of total billed charges,,,,,,50.53,,,fee schedule,,,,,,,,,,,,,,service not payable,48.74,,,case rate,,,,,,,,,,,,,,service not payable,49.38,,,fee schedule,,,,,,29.38,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,49.38,,,case rate,,,,,,,,,,,,,,service not payable,48.74,,,case rate,,,,,,,,,,,,,,service not payable,734,,,percent of total billed charges,,,,,,330.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,550.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,734,,,percent of total billed charges,,,,,,734,,,percent of total billed charges,,,,,,734,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,734,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,734,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,734,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,623.9,,,percent of total billed charges,,,,,,288.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC INFUSION HYDRATION INIT 31M 1H,26076202,CDM,0260,RC,96360,CPT,05693,APC,,outpatient,facility,,,734,734,188.8,555.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,217.05,209.46,217.75,74,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,512.26,,,fee schedule,,,,,,537.53,,,fee schedule,,,,,,337.62,,,fee schedule,,,,,,218.57,,,fee schedule,,,,,,477.56,,,fee schedule,,,,,,,,,,,,,,,222.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,208.11,194.15,208.11,1 through 10,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,222.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,208.11,208.11,208.11,1 through 10,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,266.54,,,fee schedule,,,,,,226.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,333.18,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,199.91,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,555.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.67,,,fee schedule,,,,,,234.1,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,222.9,209.46,224.92,1 through 10,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.57,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,388.71,,,fee schedule,,,,,,218.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,199.91,,,fee schedule,,,,,,,,,,,,,,,222.12,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC INFUSION HYDRATION INIT 31M 1H,26076202,CDM,0260,RC,96360,CPT,111,EAPG,,outpatient,facility,,,734,734,175.54,196.6,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.09,,,fee schedule,,,,,,,,,,,,,,,184.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,196.6,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC INFUSIONHYDRATIONEA ADDTL HR,26076203,CDM,0260,RC,96361,CPT,,,,inpatient,facility,,,258,258,116.1,258,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,
HC INFUSIONHYDRATIONEA ADDTL HR,26076203,CDM,0260,RC,96361,CPT,,,,outpatient,facility,,,258,258,11.15,278,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,121.26,,,percent of total billed charges,,,,,,130.57,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.86,,,percent of total billed charges,,,,,,196.08,,,percent of total billed charges,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,188.34,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,180.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,61.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",130.57,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,108.36,43.77,284.6,49,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",180.6,,,percent of total billed charges,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,133.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,110.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,13.26,,,fee schedule,,,,,,,,,,,,,,service not payable,12.91,,,case rate,,,,,,,,,,,,,,service not payable,13.08,,,fee schedule,,,,,,11.15,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13.08,,,case rate,,,,,,,,,,,,,,service not payable,12.91,,,case rate,,,,,,,,,,,,,,service not payable,258,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.3,,,percent of total billed charges,,,,,,143.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,128.93,14.32,128.93,1 through 10,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum 
HC INFUSIONHYDRATIONEA ADDTL HR,26076203,CDM,0260,RC,96361,CPT,05691,APC,,outpatient,facility,,,258,258,41.56,122.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,48.16,47.2,96.09,246,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,112.78,,,fee schedule,,,,,,118.34,,,fee schedule,,,,,,74.33,,,fee schedule,,,,,,48.12,,,fee schedule,,,,,,105.13,,,fee schedule,,,,,,,,,,,,,,,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,45.57,43.03,91.14,12,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,45.57,43.03,96.24,1 through 10,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,58.68,,,fee schedule,,,,,,49.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,73.35,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,44.01,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,122.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.32,,,fee schedule,,,,,,51.54,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,48.81,48.81,49.55,17,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.12,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,85.58,,,fee schedule,,,,,,48.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,44.01,,,fee schedule,,,,,,,,,,,,,,,48.9,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC INFUSIONHYDRATIONEA ADDTL HR,26076203,CDM,0260,RC,96361,CPT,110,EAPG,,outpatient,facility,,,258,258,323.32,362.12,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.65,,,fee schedule,,,,,,,,,,,,,,,339.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,362.12,,,fee schedule,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC TX PROPH DG ADDL SEQ IV INF,26076204,CDM,0260,RC,96367,CPT,,,,inpatient,facility,,,406.5,406.5,182.93,406.5,,,,,,,,,,,,,,,,,,,,345.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,284.55,,,percent of total billed charges,,,,,,243.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,345.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,406.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,182.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.52,,,percent of total billed charges,,,,,,,,,,,,,,
HC TX PROPH DG ADDL SEQ IV INF,26076204,CDM,0260,RC,96367,CPT,,,,outpatient,facility,,,406.5,406.5,25.35,406.5,,264.23,,,percent of total billed charges,,,,,,,,,,,,,,,345.52,,,percent of total billed charges,,,,,,,,,,,,,,,191.06,,,percent of total billed charges,,,,,,149.65,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,272.36,,,percent of total billed charges,,,,,,308.94,,,percent of total billed charges,,,,,,406.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,296.75,,,percent of total billed charges,,,,,,304.88,,,percent of total billed charges,,,,,,284.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,264.23,,,percent of total billed charges,,,,,,97.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",149.65,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,406.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,170.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,170.73,137.82,406.5,24,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",284.55,,,percent of total billed charges,,,,,,,,,,,,,,,406.5,,,percent of total billed charges,,,,,,152.71,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,288.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,284.55,,,percent of total billed charges,,,,,,243.9,,,percent of total billed charges,,,,,,182.93,,,percent of total billed charges,,,,,,,,,,,,,,,345.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.5,,,percent of total billed charges,,,,,,406.5,,,percent of total billed charges,,,,,,174.79,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,406.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,406.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.88,,,percent of total billed charges,,,,,,27.17,,,fee schedule,,,,,,,,,,,,,,service not payable,25.35,,,case rate,,,,,,,,,,,,,,service not payable,26.44,,,fee schedule,,,,,,25.98,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,26.44,,,case rate,,,,,,,,,,,,,,service not payable,25.35,,,case rate,,,,,,,,,,,,,,service not payable,406.5,,,percent of total billed charges,,,,,,182.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,406.5,,,percent of total billed charges,,,,,,406.5,,,percent of total billed charges,,,,,,406.5,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,406.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,406.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,406.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,345.52,,,percent of total billed charges,,,,,,164.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC TX PROPH DG ADDL SEQ IV INF,26076204,CDM,0260,RC,96367,CPT,05692,APC,,outpatient,facility,,,406.5,406.5,63.91,187.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,72.81,72.81,73.81,13,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,173.41,,,fee schedule,,,,,,181.96,,,fee schedule,,,,,,114.29,,,fee schedule,,,,,,73.99,,,fee schedule,,,,,,161.66,,,fee schedule,,,,,,,,,,,,,,,75.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,70.3,70.3,140.59,1 through 10,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,75.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,70.3,70.3,147.97,1 through 10,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.23,,,fee schedule,,,,,,76.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,112.79,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,67.67,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,187.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.45,,,fee schedule,,,,,,79.25,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.99,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,131.58,,,fee schedule,,,,,,73.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,67.67,,,fee schedule,,,,,,,,,,,,,,,75.19,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC TX PROPH DG ADDL SEQ IV INF,26076204,CDM,0260,RC,96367,CPT,111,EAPG,,outpatient,facility,,,406.5,406.5,175.54,196.6,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.09,,,fee schedule,,,,,,,,,,,,,,,184.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,196.6,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER DIAG CONCURRENT INF,26076205,CDM,0260,RC,96368,CPT,,,,inpatient,facility,,,341.5,341.5,153.68,341.5,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,239.05,,,percent of total billed charges,,,,,,204.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,153.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,,,,,,
HC THER DIAG CONCURRENT INF,26076205,CDM,0260,RC,96368,CPT,,,,outpatient,facility,,,341.5,341.5,16.01,341.5,,221.97,,,percent of total billed charges,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,,,,,102.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,160.5,,,percent of total billed charges,,,,,,230.52,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,225.39,,,percent of total billed charges,,,,,,64.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,64.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,228.81,,,percent of total billed charges,,,,,,259.54,,,percent of total billed charges,,,,,,341.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,249.29,,,percent of total billed charges,,,,,,256.12,,,percent of total billed charges,,,,,,239.05,,,percent of total billed charges,,,,,,239.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,221.97,,,percent of total billed charges,,,,,,81.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",230.52,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,341.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.43,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,144.35,25.76,171.97,38,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",239.05,,,percent of total billed charges,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,138.36,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,242.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,239.05,,,percent of total billed charges,,,,,,204.9,,,percent of total billed charges,,,,,,153.68,,,percent of total billed charges,,,,,,,,,,,,,,,290.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,341.5,,,percent of total billed charges,,,,,,146.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,341.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,341.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.12,,,percent of total billed charges,,,,,,16.01,,,fee schedule,,,,,,,,,,,,,,service not payable,17.3,,,case rate,,,,,,,,,,,,,,service not payable,17.45,,,fee schedule,,,,,,17.33,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,17.45,,,case rate,,,,,,,,,,,,,,service not payable,17.3,,,case rate,,,,,,,,,,,,,,service not payable,341.5,,,percent of total billed charges,,,,,,153.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.5,,,fee schedule,,,,,,341.5,,,percent of total billed charges,,,,,,341.5,,,percent of total billed charges,,,,,,341.5,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,341.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,341.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,341.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,290.27,,,percent of total billed charges,,,,,,148.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC THER DIAG CONCURRENT INF,26076205,CDM,0260,RC,96368,CPT,111,EAPG,,outpatient,facility,,,341.5,341.5,175.54,196.6,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.09,,,fee schedule,,,,,,,,,,,,,,,184.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,196.6,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC SC THERAPY INFUSION UP TO 1 HR,26076206,CDM,0260,RC,96369,CPT,,,,inpatient,facility,,,366.08,366.08,164.74,366.08,,,,,,,,,,,,,,,,,,,,311.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,259.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,256.26,,,percent of total billed charges,,,,,,219.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,311.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,366.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,164.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,311.17,,,percent of total billed charges,,,,,,,,,,,,,,
HC SC THERAPY INFUSION UP TO 1 HR,26076206,CDM,0260,RC,96369,CPT,,,,outpatient,facility,,,366.08,366.08,69.3,366.08,,237.95,,,percent of total billed charges,,,,,,,,,,,,,,,311.17,,,percent of total billed charges,,,,,,,,,,,,,,,172.06,,,percent of total billed charges,,,,,,69.3,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,245.27,,,percent of total billed charges,,,,,,278.22,,,percent of total billed charges,,,,,,366.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,267.24,,,percent of total billed charges,,,,,,274.56,,,percent of total billed charges,,,,,,256.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.95,,,percent of total billed charges,,,,,,87.86,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.3,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,366.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,153.75,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",256.26,,,percent of total billed charges,,,,,,,,,,,,,,,366.08,,,percent of total billed charges,,,,,,70.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,259.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,256.26,,,percent of total billed charges,,,,,,219.65,,,percent of total billed charges,,,,,,164.74,,,percent of total billed charges,,,,,,,,,,,,,,,311.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.08,,,percent of total billed charges,,,,,,366.08,,,percent of total billed charges,,,,,,157.41,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,366.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,366.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.56,,,percent of total billed charges,,,,,,180.14,,,fee schedule,,,,,,,,,,,,,,service not payable,163.88,,,case rate,,,,,,,,,,,,,,service not payable,149.99,,,fee schedule,,,,,,121.69,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,149.99,,,case rate,,,,,,,,,,,,,,service not payable,163.88,,,case rate,,,,,,,,,,,,,,service not payable,366.08,,,percent of total billed charges,,,,,,164.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,366.08,,,percent of total billed charges,,,,,,366.08,,,percent of total billed charges,,,,,,366.08,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,366.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,366.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,366.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,311.17,,,percent of total billed charges,,,,,,76.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SC THERAPY INFUSION UP TO 1 HR,26076206,CDM,0260,RC,96369,CPT,05693,APC,,outpatient,facility,,,366.08,366.08,188.8,555.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,512.26,,,fee schedule,,,,,,537.53,,,fee schedule,,,,,,337.62,,,fee schedule,,,,,,218.57,,,fee schedule,,,,,,477.56,,,fee schedule,,,,,,,,,,,,,,,222.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,222.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,266.54,,,fee schedule,,,,,,226.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,333.18,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,199.91,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,555.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.67,,,fee schedule,,,,,,234.1,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.57,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,388.71,,,fee schedule,,,,,,218.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,199.91,,,fee schedule,,,,,,,,,,,,,,,222.12,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC SC THERAPY INFUSION UP TO 1 HR,26076206,CDM,0260,RC,96369,CPT,111,EAPG,,outpatient,facility,,,366.08,366.08,175.54,196.6,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.09,,,fee schedule,,,,,,,,,,,,,,,184.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,196.6,,,fee schedule,,,,,,,,,,,,,,,175.54,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH DIAG INJSC IM,26076207,CDM,0260,RC,96372,CPT,,,,inpatient,facility,,,258,258,116.1,258,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,
HC THER PROPH DIAG INJSC IM,26076207,CDM,0260,RC,96372,CPT,,,,outpatient,facility,,,258,258,12.23,278,,167.7,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,121.26,,,percent of total billed charges,,,,,,108.48,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,170.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.86,,,percent of total billed charges,,,,,,196.08,,,percent of total billed charges,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,188.34,,,percent of total billed charges,,,,,,193.5,,,percent of total billed charges,,,,,,180.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.7,,,percent of total billed charges,,,,,,61.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.48,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,258,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,108.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,108.36,72.41,132.83,102,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",180.6,,,percent of total billed charges,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,110.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,110.69,110.69,110.69,1 through 10,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,183.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,180.6,,,percent of total billed charges,,,,,,154.8,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,219.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,110.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,22.03,,,fee schedule,,,,,,,,,,,,,,service not payable,21.19,,,case rate,,,,,,,,,,,,,,service not payable,21.59,,,fee schedule,,,,,,12.23,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,21.59,,,case rate,,,,,,,,,,,,,,service not payable,21.19,,,case rate,,,,,,,,,,,,,,service not payable,258,,,percent of total billed charges,,,,,,116.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,258,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,258,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.3,,,percent of total billed charges,,,,,,119.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,107.12,107.11,214.24,24,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum 
HC THER PROPH DIAG INJSC IM,26076207,CDM,0260,RC,96372,CPT,05692,APC,,outpatient,facility,,,258,258,63.91,187.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,72.81,72.81,73.11,54,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,173.41,,,fee schedule,,,,,,181.96,,,fee schedule,,,,,,114.29,,,fee schedule,,,,,,73.99,,,fee schedule,,,,,,161.66,,,fee schedule,,,,,,,,,,,,,,,75.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,70.3,63.81,70.3,1 through 10,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.23,,,fee schedule,,,,,,76.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,112.79,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,67.67,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,187.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.45,,,fee schedule,,,,,,79.25,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.99,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,131.58,,,fee schedule,,,,,,73.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,67.67,,,fee schedule,,,,,,,,,,,,,,,75.19,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH DIAG INJSC IM,26076207,CDM,0260,RC,96372,CPT,109,EAPG,,outpatient,facility,,,258,258,32.32,36.2,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.55,,,fee schedule,,,,,,,,,,,,,,,33.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,36.2,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH DIAG INJIV PUSH,26076208,CDM,0260,RC,96374,CPT,,,,inpatient,facility,,,493.58,493.58,222.11,493.58,,,,,,,,,,,,,,,,,,,,419.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,345.51,,,percent of total billed charges,,,,,,296.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,419.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,493.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,222.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,419.54,,,percent of total billed charges,,,,,,,,,,,,,,
HC THER PROPH DIAG INJIV PUSH,26076208,CDM,0260,RC,96374,CPT,,,,outpatient,facility,,,493.58,493.58,33.62,493.58,,320.83,,,percent of total billed charges,,,,,,,,,,,,,,,419.54,,,percent of total billed charges,,,,,,,,,,,,,,,231.98,,,percent of total billed charges,,,,,,152.67,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,330.7,,,percent of total billed charges,,,,,,375.12,,,percent of total billed charges,,,,,,493.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,360.31,,,percent of total billed charges,,,,,,370.19,,,percent of total billed charges,,,,,,345.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.83,,,percent of total billed charges,,,,,,118.46,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,177.58,177.58,177.58,1 through 10,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",152.67,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,493.58,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,207.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,207.3,138.21,207.3,170,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",345.51,,,percent of total billed charges,,,,,,,,,,,,,,,493.58,,,percent of total billed charges,,,,,,155.78,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,1300,1300,1300,1 through 10,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,350.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,345.51,,,percent of total billed charges,,,,,,296.15,,,percent of total billed charges,,,,,,222.11,,,percent of total billed charges,,,,,,,,,,,,,,,419.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.58,,,percent of total billed charges,,,,,,493.58,,,percent of total billed charges,,,,,,212.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,493.58,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,493.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,493.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.18,,,percent of total billed charges,,,,,,49.66,,,fee schedule,,,,,,,,,,,,,,service not payable,48.13,,,case rate,,,,,,,,,,,,,,service not payable,49.51,,,fee schedule,,,,,,33.62,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,49.51,,,case rate,,,,,,,,,,,,,,service not payable,48.13,,,case rate,,,,,,,,,,,,,,service not payable,493.58,,,percent of total billed charges,,,,,,222.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,493.58,,,percent of total billed charges,,,,,,493.58,,,percent of total billed charges,,,,,,493.58,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,493.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,493.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,493.58,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,419.54,,,percent of total billed charges,,,,,,167.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,150.75,150.75,405.24,18,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum 
HC THER PROPH DIAG INJIV PUSH,26076208,CDM,0260,RC,96374,CPT,05693,APC,,outpatient,facility,,,493.58,493.58,188.8,555.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,216.79,215.55,217.75,299,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,512.26,,,fee schedule,,,,,,537.53,,,fee schedule,,,,,,337.62,,,fee schedule,,,,,,218.57,,,fee schedule,,,,,,477.56,,,fee schedule,,,,,,,,,,,,,,,222.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,208.11,194.15,218.57,19,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,222.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,208.11,194.15,208.11,30,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,266.54,,,fee schedule,,,,,,226.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,333.18,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,199.91,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,555.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,237.67,,,fee schedule,,,,,,234.1,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,222.9,222.9,223.43,31,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.57,,,fee schedule,,,,,,222.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,388.71,,,fee schedule,,,,,,218.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,,,,,,,,,,277.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,199.91,,,fee schedule,,,,,,,,,,,,,,,222.12,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.23,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH DIAG INJIV PUSH,26076208,CDM,0260,RC,96374,CPT,109,EAPG,,outpatient,facility,,,493.58,493.58,32.32,36.2,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.55,,,fee schedule,,,,,,,,,,,,,,,33.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,36.2,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH IV PUSH SEQ NEW DRUG,26076209,CDM,0260,RC,96375,CPT,,,,inpatient,facility,,,349,349,157.05,349,,,,,,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,244.3,,,percent of total billed charges,,,,,,209.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,349,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,157.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,,,,,,,,,,,,
HC THER PROPH IV PUSH SEQ NEW DRUG,26076209,CDM,0260,RC,96375,CPT,,,,outpatient,facility,,,349,349,13.7,349,,226.85,,,percent of total billed charges,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,,,,,,,,,,,,,164.03,,,percent of total billed charges,,,,,,135.59,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,233.83,,,percent of total billed charges,,,,,,265.24,,,percent of total billed charges,,,,,,349,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,254.77,,,percent of total billed charges,,,,,,261.75,,,percent of total billed charges,,,,,,244.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.85,,,percent of total billed charges,,,,,,83.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,39.36,39.36,907.4,1 through 10,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",135.59,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,349,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,146.58,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,293.16,121.07,687.97,180,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",244.3,,,percent of total billed charges,,,,,,,,,,,,,,,349,,,percent of total billed charges,,,,,,138.36,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,247.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,244.3,,,percent of total billed charges,,,,,,209.4,,,percent of total billed charges,,,,,,157.05,,,percent of total billed charges,,,,,,,,,,,,,,,296.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349,,,percent of total billed charges,,,,,,349,,,percent of total billed charges,,,,,,150.07,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,349,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,349,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,349,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.75,,,percent of total billed charges,,,,,,19.26,,,fee schedule,,,,,,,,,,,,,,service not payable,18.89,,,case rate,,,,,,,,,,,,,,service not payable,18.99,,,fee schedule,,,,,,13.7,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,18.99,,,case rate,,,,,,,,,,,,,,service not payable,18.89,,,case rate,,,,,,,,,,,,,,service not payable,349,,,percent of total billed charges,,,,,,157.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,349,,,percent of total billed charges,,,,,,349,,,percent of total billed charges,,,,,,349,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,349,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,349,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,349,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,296.65,,,percent of total billed charges,,,,,,148.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,133.89,103.22,401.68,1 through 10,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum 
HC THER PROPH IV PUSH SEQ NEW DRUG,26076209,CDM,0260,RC,96375,CPT,05691,APC,,outpatient,facility,,,349,349,41.56,122.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,47.2,47.2,142.4,281,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,112.78,,,fee schedule,,,,,,118.34,,,fee schedule,,,,,,74.33,,,fee schedule,,,,,,48.12,,,fee schedule,,,,,,105.13,,,fee schedule,,,,,,,,,,,,,,,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,91.14,43.03,182.28,15,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,48.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,91.14,43.03,136.71,30,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,58.68,,,fee schedule,,,,,,49.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,73.35,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,44.01,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,122.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.32,,,fee schedule,,,,,,51.54,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,48.81,48.81,146.43,20,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.12,,,fee schedule,,,,,,48.9,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,48.9,,,fee schedule,,,,,,85.58,,,fee schedule,,,,,,48.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,,,,,,,,,,61.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,44.01,,,fee schedule,,,,,,,,,,,,,,,48.9,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC THER PROPH IV PUSH SEQ NEW DRUG,26076209,CDM,0260,RC,96375,CPT,109,EAPG,,outpatient,facility,,,349,349,32.32,36.2,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.55,,,fee schedule,,,,,,,,,,,,,,,33.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,36.2,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC TX PROPH DX INJ SAME DRUG ADD ON,26076210,CDM,0260,RC,96376,CPT,,,,inpatient,facility,,,312,312,140.4,312,,,,,,,,,,,,,,,,,,,,265.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.4,,,percent of total billed charges,,,,,,187.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,265.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,312,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,140.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.2,,,percent of total billed charges,,,,,,,,,,,,,,
HC TX PROPH DX INJ SAME DRUG ADD ON,26076210,CDM,0260,RC,96376,CPT,,,,outpatient,facility,,,312,312,59.28,312,,202.8,,,percent of total billed charges,,,,,,,,,,,,,,,265.2,,,percent of total billed charges,,,,,,93.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,146.64,,,percent of total billed charges,,,,,,127.56,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.92,,,percent of total billed charges,,,,,,59.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,59.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,209.04,,,percent of total billed charges,,,,,,237.12,,,percent of total billed charges,,,,,,312,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,227.76,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,,218.4,,,percent of total billed charges,,,,,,218.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,202.8,,,percent of total billed charges,,,,,,74.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",127.56,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,312,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.04,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,87.44,6.04,131.04,1 through 10,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",218.4,,,percent of total billed charges,,,,,,,,,,,,,,,312,,,percent of total billed charges,,,,,,130.15,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,221.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.4,,,percent of total billed charges,,,,,,187.2,,,percent of total billed charges,,,,,,140.4,,,percent of total billed charges,,,,,,,,,,,,,,,265.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312,,,percent of total billed charges,,,,,,312,,,percent of total billed charges,,,,,,134.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,312,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,312,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,312,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,312,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,,,,,,,,,service not payable,312,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,service not payable,312,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,312,,,percent of total billed charges,,,,,,140.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312,,,fee schedule,,,,,,312,,,percent of total billed charges,,,,,,312,,,percent of total billed charges,,,,,,312,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,312,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,312,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,312,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,265.2,,,percent of total billed charges,,,,,,139.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC TX PROPH DX INJ SAME DRUG ADD ON,26076210,CDM,0260,RC,96376,CPT,109,EAPG,,outpatient,facility,,,312,312,32.32,36.2,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.55,,,fee schedule,,,,,,,,,,,,,,,33.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,36.2,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC PROLONGED    8 HRS  IV INF FOR TX DXREQ PORTABL,26076211,CDM,0260,RC,C8957,HCPCS,,,,inpatient,facility,,,770.05,770.05,346.52,770.05,,,,,,,,,,,,,,,,,,,,654.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,546.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,539.04,,,percent of total billed charges,,,,,,462.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,654.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,770.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,770.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,346.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,654.54,,,percent of total billed charges,,,,,,,,,,,,,,
HC PROLONGED    8 HRS  IV INF FOR TX DXREQ PORTABL,26076211,CDM,0260,RC,C8957,HCPCS,,,,outpatient,facility,,,770.05,770.05,129.72,770.05,,770.05,,,fee schedule,,,,,,,,,,,,,,,654.54,,,percent of total billed charges,,,,,,,,,,,,,,,607,,FormulaCPE:  {Units in Service Type} * 607.00 End FormulaCPE,other,,,,0,FormulaCPE:  {Units in Service Type} * 607.00 End FormulaCPE; Zero instances of the item or service in the 15 months prior to posting the file.,519.79,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,515.93,,,percent of total billed charges,,,,,,585.24,,,percent of total billed charges,,,,,,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,562.14,,,percent of total billed charges,,,,,,577.53,,,percent of total billed charges,,,,,,539.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.53,,,percent of total billed charges,,,,,,184.81,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",519.79,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,770.05,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,323.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,323.42,323.42,323.42,1 through 10,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",539.03,,,percent of total billed charges,,,,,,,,,,,,,,,770.05,,,percent of total billed charges,,,,,,537.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,546.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,539.04,,,percent of total billed charges,,,,,,462.03,,,percent of total billed charges,,,,,,346.52,,,percent of total billed charges,,,,,,,,,,,,,,,654.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,770.05,,,percent of total billed charges,,,,,,770.05,,,percent of total billed charges,,,,,,331.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,770.05,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,770.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.54,,,percent of total billed charges,,,,,,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,770.05,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,770.05,,,percent of total billed charges,,,,,,346.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.12,,,fee schedule,,,,,,770.05,,,percent of total billed charges,,,,,,770.05,,,percent of total billed charges,,,,,,770.05,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,770.05,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,654.54,,,percent of total billed charges,,,,,,577.54,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC PROLONGED    8 HRS  IV INF FOR TX DXREQ PORTABL,26076211,CDM,0260,RC,C8957,HCPCS,05694,APC,,outpatient,facility,,,770.05,770.05,293.19,862.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,431.16,,,fee schedule,,,,,,795.49,,,fee schedule,,,,,,834.73,,,fee schedule,,,,,,524.29,,,fee schedule,,,,,,339.41,,,fee schedule,,,,,,741.6,,,fee schedule,,,,,,,,,,,,,,,344.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,344.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,293.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,413.92,,,fee schedule,,,,,,351.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.93,,,fee schedule,,,,,,344.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.93,,,fee schedule,,,,,,,,,,,,,,,517.4,,,fee schedule,,,,,,344.93,,,fee schedule,,,,,,310.44,,,fee schedule,,,,,,344.93,,,fee schedule,,,,,,862.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.08,,,fee schedule,,,,,,363.54,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",344.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.41,,,fee schedule,,,,,,344.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,344.93,,,fee schedule,,,,,,603.63,,,fee schedule,,,,,,339.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,431.16,,,fee schedule,,,,,,,,,,,,,,,431.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,310.44,,,fee schedule,,,,,,,,,,,,,,,344.93,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,362.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC PROLONGED    8 HRS  IV INF FOR TX DXREQ PORTABL,26076211,CDM,0260,RC,C8957,HCPCS,110,EAPG,,outpatient,facility,,,770.05,770.05,323.32,362.12,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,355.65,,,fee schedule,,,,,,,,,,,,,,,339.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,362.12,,,fee schedule,,,,,,,,,,,,,,,323.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC IV INFUSION SQ AND POST ADMIN MONITORING  CASIR,26076212,CDM,0260,RC,M0243,HCPCS,,,,inpatient,facility,,,1067,1067,480.15,1067,,,,,,,,,,,,,,,,,,,,906.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,693.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,757.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,746.9,,,percent of total billed charges,,,,,,640.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,906.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1067,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1067,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,480.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,906.95,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV INFUSION SQ AND POST ADMIN MONITORING  CASIR,26076212,CDM,0260,RC,M0243,HCPCS,,,,outpatient,facility,,,1067,1067,129.72,1067,,693.55,,,percent of total billed charges,,,,,,,,,,,,,,,906.95,,,percent of total billed charges,,,,,,320.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,501.49,,,percent of total billed charges,,,,,,720.23,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,704.22,,,percent of total billed charges,,,,,,202.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,202.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,714.89,,,percent of total billed charges,,,,,,810.92,,,percent of total billed charges,,,,,,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,778.91,,,percent of total billed charges,,,,,,800.25,,,percent of total billed charges,,,,,,746.9,,,percent of total billed charges,,,,,,746.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,533.5,,,fee schedule,,,,,,533.5,,,fee schedule,,,,,,693.55,,,percent of total billed charges,,,,,,256.08,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",720.23,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1067,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,450,,,fee schedule,,,,,,746.9,,,percent of total billed charges,,,,,,,,,,,,,,,1067,,,percent of total billed charges,,,,,,744.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,757.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,746.9,,,percent of total billed charges,,,,,,640.2,,,percent of total billed charges,,,,,,480.15,,,percent of total billed charges,,,,,,,,,,,,,,,906.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1067,,,percent of total billed charges,,,,,,1067,,,percent of total billed charges,,,,,,458.81,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1067,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1067,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.25,,,percent of total billed charges,,,,,,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1067,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1067,,,percent of total billed charges,,,,,,480.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1067,,,fee schedule,,,,,,1067,,,percent of total billed charges,,,,,,1067,,,percent of total billed charges,,,,,,1067,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1067,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,906.95,,,percent of total billed charges,,,,,,800.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV INFUSION AND POST ADMIN MONITORING  BAMLAN A,26076213,CDM,0260,RC,M0245,HCPCS,,,,inpatient,facility,,,804.96,804.96,362.23,804.96,,,,,,,,,,,,,,,,,,,,684.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,603.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,571.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,563.47,,,percent of total billed charges,,,,,,482.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,684.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,804.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,603.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,804.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,362.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.22,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV INFUSION AND POST ADMIN MONITORING  BAMLAN A,26076213,CDM,0260,RC,M0245,HCPCS,,,,outpatient,facility,,,804.96,804.96,129.72,804.96,,523.22,,,percent of total billed charges,,,,,,,,,,,,,,,684.22,,,percent of total billed charges,,,,,,241.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,378.33,,,percent of total billed charges,,,,,,543.35,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,531.27,,,percent of total billed charges,,,,,,152.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,152.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,539.32,,,percent of total billed charges,,,,,,611.77,,,percent of total billed charges,,,,,,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,587.62,,,percent of total billed charges,,,,,,603.72,,,percent of total billed charges,,,,,,563.47,,,percent of total billed charges,,,,,,563.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,402.48,,,fee schedule,,,,,,402.48,,,fee schedule,,,,,,523.22,,,percent of total billed charges,,,,,,193.19,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",543.35,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,804.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,450,,,fee schedule,,,,,,563.47,,,percent of total billed charges,,,,,,,,,,,,,,,804.96,,,percent of total billed charges,,,,,,561.46,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,571.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,563.47,,,percent of total billed charges,,,,,,482.98,,,percent of total billed charges,,,,,,362.23,,,percent of total billed charges,,,,,,,,,,,,,,,684.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,804.96,,,percent of total billed charges,,,,,,804.96,,,percent of total billed charges,,,,,,346.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,804.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,804.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,603.72,,,percent of total billed charges,,,,,,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,804.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,804.96,,,percent of total billed charges,,,,,,362.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,603.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,804.96,,,fee schedule,,,,,,804.96,,,percent of total billed charges,,,,,,804.96,,,percent of total billed charges,,,,,,804.96,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,804.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,684.22,,,percent of total billed charges,,,,,,603.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV INFUSION AND POST ADMIN MONITORING  SOTROVIM,26076214,CDM,0260,RC,M0247,HCPCS,,,,inpatient,facility,,,1126.25,1126.25,506.81,1126.25,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,799.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,788.38,,,percent of total billed charges,,,,,,675.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV INFUSION AND POST ADMIN MONITORING  SOTROVIM,26076214,CDM,0260,RC,M0247,HCPCS,,,,outpatient,facility,,,1126.25,1126.25,129.72,1126.25,,732.06,,,percent of total billed charges,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,337.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,529.34,,,percent of total billed charges,,,,,,760.22,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.33,,,percent of total billed charges,,,,,,213.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,213.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,754.59,,,percent of total billed charges,,,,,,855.95,,,percent of total billed charges,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,822.16,,,percent of total billed charges,,,,,,844.69,,,percent of total billed charges,,,,,,788.38,,,percent of total billed charges,,,,,,788.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,563.13,,,fee schedule,,,,,,563.13,,,fee schedule,,,,,,732.06,,,percent of total billed charges,,,,,,270.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",760.22,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1126.25,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,450,,,fee schedule,,,,,,788.38,,,percent of total billed charges,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,785.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,799.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,788.38,,,percent of total billed charges,,,,,,675.75,,,percent of total billed charges,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,484.29,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,,percent of total billed charges,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,fee schedule,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,957.31,,,percent of total billed charges,,,,,,844.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IV INJECTION AND POST ADMIN MONITORING  BEBTELO,26076215,CDM,0260,RC,M0222,HCPCS,,,,inpatient,facility,,,1126.25,1126.25,506.81,1126.25,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,799.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,788.38,,,percent of total billed charges,,,,,,675.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,
HC IV INJECTION AND POST ADMIN MONITORING  BEBTELO,26076215,CDM,0260,RC,M0222,HCPCS,,,,outpatient,facility,,,1126.25,1126.25,129.72,1126.25,,732.06,,,percent of total billed charges,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,337.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,529.34,,,percent of total billed charges,,,,,,760.22,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.33,,,percent of total billed charges,,,,,,213.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,213.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,754.59,,,percent of total billed charges,,,,,,855.95,,,percent of total billed charges,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,822.16,,,percent of total billed charges,,,,,,844.69,,,percent of total billed charges,,,,,,788.38,,,percent of total billed charges,,,,,,788.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,563.13,,,fee schedule,,,,,,563.13,,,fee schedule,,,,,,732.06,,,percent of total billed charges,,,,,,270.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",760.22,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1126.25,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,473.02,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",788.38,,,percent of total billed charges,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,785.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,799.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,788.38,,,percent of total billed charges,,,,,,675.75,,,percent of total billed charges,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,484.29,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,,percent of total billed charges,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,fee schedule,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,957.31,,,percent of total billed charges,,,,,,844.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC INJECTION AND POST ADMIN MONITORING  TIXAGEVIMA,26076216,CDM,0260,RC,M0220,HCPCS,,,,inpatient,facility,,,1126.25,1126.25,506.81,1126.25,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,799.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,788.38,,,percent of total billed charges,,,,,,675.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,
HC INJECTION AND POST ADMIN MONITORING  TIXAGEVIMA,26076216,CDM,0260,RC,M0220,HCPCS,,,,outpatient,facility,,,1126.25,1126.25,129.72,1126.25,,732.06,,,percent of total billed charges,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,337.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,529.34,,,percent of total billed charges,,,,,,760.22,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,743.33,,,percent of total billed charges,,,,,,213.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,213.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,754.59,,,percent of total billed charges,,,,,,855.95,,,percent of total billed charges,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,822.16,,,percent of total billed charges,,,,,,844.69,,,percent of total billed charges,,,,,,788.38,,,percent of total billed charges,,,,,,788.38,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,563.13,,,fee schedule,,,,,,563.13,,,fee schedule,,,,,,732.06,,,percent of total billed charges,,,,,,270.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",760.22,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1126.25,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,150.5,,,fee schedule,,,,,,788.38,,,percent of total billed charges,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,785.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,799.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,788.38,,,percent of total billed charges,,,,,,675.75,,,percent of total billed charges,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,957.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,484.29,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1126.25,,,percent of total billed charges,,,,,,506.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1126.25,,,fee schedule,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,1126.25,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1126.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,957.31,,,percent of total billed charges,,,,,,844.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC INJ THERAPEUTIC DX SQ OR IM,26094534,CDM,0260,RC,96372,CPT,,,,inpatient,facility,,,253.12,253.12,113.9,253.12,,,,,,,,,,,,,,,,,,,,215.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,177.18,,,percent of total billed charges,,,,,,151.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,215.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,253.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,113.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.15,,,percent of total billed charges,,,,,,,,,,,,,,
HC INJ THERAPEUTIC DX SQ OR IM,26094534,CDM,0260,RC,96372,CPT,,,,outpatient,facility,,,253.12,253.12,12.23,278,,164.53,,,percent of total billed charges,,,,,,,,,,,,,,,215.15,,,percent of total billed charges,,,,,,,,,,,,,,,118.97,,,percent of total billed charges,,,,,,108.48,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,169.59,,,percent of total billed charges,,,,,,192.37,,,percent of total billed charges,,,,,,253.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.78,,,percent of total billed charges,,,,,,189.84,,,percent of total billed charges,,,,,,177.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.53,,,percent of total billed charges,,,,,,60.75,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.48,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,253.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,106.31,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",177.18,,,percent of total billed charges,,,,,,,,,,,,,,,253.12,,,percent of total billed charges,,,,,,110.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,179.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,177.18,,,percent of total billed charges,,,,,,151.87,,,percent of total billed charges,,,,,,113.9,,,percent of total billed charges,,,,,,,,,,,,,,,215.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.12,,,percent of total billed charges,,,,,,253.12,,,percent of total billed charges,,,,,,108.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,253.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,253.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.84,,,percent of total billed charges,,,,,,22.03,,,fee schedule,,,,,,,,,,,,,,service not payable,21.19,,,case rate,,,,,,,,,,,,,,service not payable,21.59,,,fee schedule,,,,,,12.23,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,21.59,,,case rate,,,,,,,,,,,,,,service not payable,21.19,,,case rate,,,,,,,,,,,,,,service not payable,253.12,,,percent of total billed charges,,,,,,113.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,189.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,253.12,,,percent of total billed charges,,,,,,253.12,,,percent of total billed charges,,,,,,253.12,,,percent of total billed charges,,,,,,277,,,per diem,,,,,,,,,,,,,,,278,,,per diem,,,,,,253.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,253.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,253.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,215.15,,,percent of total billed charges,,,,,,119.02,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC INJ THERAPEUTIC DX SQ OR IM,26094534,CDM,0260,RC,96372,CPT,05692,APC,,outpatient,facility,,,253.12,253.12,63.91,187.97,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,173.41,,,fee schedule,,,,,,181.96,,,fee schedule,,,,,,114.29,,,fee schedule,,,,,,73.99,,,fee schedule,,,,,,161.66,,,fee schedule,,,,,,,,,,,,,,,75.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,90.23,,,fee schedule,,,,,,76.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,112.79,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,67.67,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,187.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.45,,,fee schedule,,,,,,79.25,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.99,,,fee schedule,,,,,,75.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,75.19,,,fee schedule,,,,,,131.58,,,fee schedule,,,,,,73.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,,,,,,,,,,93.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,67.67,,,fee schedule,,,,,,,,,,,,,,,75.19,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC INJ THERAPEUTIC DX SQ OR IM,26094534,CDM,0260,RC,96372,CPT,109,EAPG,,outpatient,facility,,,253.12,253.12,32.32,36.2,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.55,,,fee schedule,,,,,,,,,,,,,,,33.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,36.2,,,fee schedule,,,,,,,,,,,,,,,32.32,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SCR SMI R T LOCK 5.0 X 45,26119,CDM,0278,RC,,,,,,inpatient,facility,,,169,169,76.05,169,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.16,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,109.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T LOCK 5.0 X 45,26119,CDM,0278,RC,,,,,,outpatient,facility,,,169,169,32.11,169,,109.85,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,50.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126.75,,,percent of total billed charges,,,,,,118.3,,,percent of total billed charges,,,,,,118.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.85,,,percent of total billed charges,,,,,,40.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,169,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.3,,,percent of total billed charges,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,117.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,72.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,fee schedule,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.65,,,percent of total billed charges,,,,,,126.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATELLA DEP 3 PEG LCS STD,26123,CDM,0278,RC,,,,,,inpatient,facility,,,1813,1813,815.85,1813,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1450.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1359.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,997.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1095.96,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1287.23,,,percent of total billed charges,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1269.1,,,percent of total billed charges,,,,,,1087.8,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1813,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1359.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1813,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,815.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1541.05,,,percent of total billed charges,,,,,,1178.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATELLA DEP 3 PEG LCS STD,26123,CDM,0278,RC,,,,,,outpatient,facility,,,1813,1813,129.72,1813,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1541.05,,,percent of total billed charges,,,,,,543.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,344.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,344.47,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1359.75,,,percent of total billed charges,,,,,,1269.1,,,percent of total billed charges,,,,,,1269.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1178.45,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1813,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1269.1,,,percent of total billed charges,,,,,,997.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,,percent of total billed charges,,,,,,1264.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1287.23,,,percent of total billed charges,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1269.1,,,percent of total billed charges,,,,,,1087.8,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,997.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,,percent of total billed charges,,,,,,1813,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1813,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1359.75,,,percent of total billed charges,,,,,,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1813,,,percent of total billed charges,,,,,,815.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1359.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1813,,,fee schedule,,,,,,1813,,,percent of total billed charges,,,,,,1813,,,percent of total billed charges,,,,,,1813,,,percent of total billed charges,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,997.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1813,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1541.05,,,percent of total billed charges,,,,,,1359.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INSERT DEP TIBIA PFC STAB 3 X 8.0,26152,CDM,0278,RC,,,,,,inpatient,facility,,,1155,1155,519.75,1155,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,981.75,,,percent of total billed charges,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,924,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,866.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,635.25,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,698.2,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",820.05,,,percent of total billed charges,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,808.5,,,percent of total billed charges,,,,,,693,,,percent of total billed charges,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,981.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.25,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1155,,,percent of total billed charges,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,866.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1155,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,981.75,,,percent of total billed charges,,,,,,750.75,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
INSERT DEP TIBIA PFC STAB 3 X 8.0,26152,CDM,0278,RC,,,,,,outpatient,facility,,,1155,1155,129.72,1155,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,981.75,,,percent of total billed charges,,,,,,346.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.45,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,866.26,,,percent of total billed charges,,,,,,808.5,,,percent of total billed charges,,,,,,808.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,750.75,,,percent of total billed charges,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1155,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,808.5,,,percent of total billed charges,,,,,,635.25,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1155,,,percent of total billed charges,,,,,,805.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,820.05,,,percent of total billed charges,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,808.5,,,percent of total billed charges,,,,,,693,,,percent of total billed charges,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,981.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.25,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1155,,,percent of total billed charges,,,,,,1155,,,percent of total billed charges,,,,,,635.25,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1155,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1155,,,percent of total billed charges,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,866.25,,,percent of total billed charges,,,,,,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1155,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1155,,,percent of total billed charges,,,,,,519.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1155,,,fee schedule,,,,,,1155,,,percent of total billed charges,,,,,,1155,,,percent of total billed charges,,,,,,1155,,,percent of total billed charges,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,635.25,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1155,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,981.75,,,percent of total billed charges,,,,,,866.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEM DEP KNEE PFC SIGMA SUB RT SZ5,26153,CDM,0278,RC,,,,,,inpatient,facility,,,4280,4280,1926,4280,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,3638,,,percent of total billed charges,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3424,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3210,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2354,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2587.26,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3038.8,,,percent of total billed charges,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2996,,,percent of total billed charges,,,,,,2568,,,percent of total billed charges,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3638,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4280,,,percent of total billed charges,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4280,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1926,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3638,,,percent of total billed charges,,,,,,2782,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEM DEP KNEE PFC SIGMA SUB RT SZ5,26153,CDM,0278,RC,,,,,,outpatient,facility,,,4280,4280,129.72,4280,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3638,,,percent of total billed charges,,,,,,1284,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,813.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,813.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3210,,,percent of total billed charges,,,,,,2996,,,percent of total billed charges,,,,,,2996,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2782,,,percent of total billed charges,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4280,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2996,,,percent of total billed charges,,,,,,2354,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4280,,,percent of total billed charges,,,,,,2985.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3038.8,,,percent of total billed charges,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2996,,,percent of total billed charges,,,,,,2568,,,percent of total billed charges,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3638,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2354,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4280,,,percent of total billed charges,,,,,,4280,,,percent of total billed charges,,,,,,2354,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4280,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4280,,,percent of total billed charges,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3210,,,percent of total billed charges,,,,,,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4280,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4280,,,percent of total billed charges,,,,,,1926,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4280,,,fee schedule,,,,,,4280,,,percent of total billed charges,,,,,,4280,,,percent of total billed charges,,,,,,4280,,,percent of total billed charges,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2354,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4280,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3638,,,percent of total billed charges,,,,,,3210,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH BALL LINEAR IAB 7.5FR 15 X 40  i,26170,CDM,0272,RC,,,,,,inpatient,facility,,,3388.73,3388.73,1524.93,3388.73,,,,,,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2541.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2202.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2406,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2372.11,,,percent of total billed charges,,,,,,2033.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2541.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1524.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,,,,,,,,,
CATH BALL LINEAR IAB 7.5FR 15 X 40  i,26170,CDM,0272,RC,,,,,,outpatient,facility,,,3388.73,3388.73,129.72,3388.73,,2202.67,,,percent of total billed charges,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,1016.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1592.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,643.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,643.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2541.54,,,percent of total billed charges,,,,,,2372.11,,,percent of total billed charges,,,,,,2372.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2202.67,,,percent of total billed charges,,,,,,813.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2287.39,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3388.73,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1423.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2372.11,,,percent of total billed charges,,,,,,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,2363.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2406,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2372.11,,,percent of total billed charges,,,,,,2033.24,,,percent of total billed charges,,,,,,1524.93,,,percent of total billed charges,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,3388.73,,,percent of total billed charges,,,,,,1457.15,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3388.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2541.55,,,percent of total billed charges,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3388.73,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3388.73,,,percent of total billed charges,,,,,,1524.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2541.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,,fee schedule,,,,,,3388.73,,,percent of total billed charges,,,,,,3388.73,,,percent of total billed charges,,,,,,3388.73,,,percent of total billed charges,,,,,,1626.59,,,percent of total billed charges,,,,,,,,,,,,,,,1999.35,,,percent of total billed charges,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2880.42,,,percent of total billed charges,,,,,,2541.55,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH BALL LINEAR IAB 7.5FR 15 X 34  i,26171,CDM,0272,RC,,,,,,inpatient,facility,,,3388.73,3388.73,1524.93,3388.73,,,,,,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2541.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2202.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2406,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2372.11,,,percent of total billed charges,,,,,,2033.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2541.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1524.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,,,,,,,,,
CATH BALL LINEAR IAB 7.5FR 15 X 34  i,26171,CDM,0272,RC,,,,,,outpatient,facility,,,3388.73,3388.73,129.72,3388.73,,2202.67,,,percent of total billed charges,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,1016.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1592.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,643.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,643.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,2541.54,,,percent of total billed charges,,,,,,2372.11,,,percent of total billed charges,,,,,,2372.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2202.67,,,percent of total billed charges,,,,,,813.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2287.39,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3388.73,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1423.27,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",2372.11,,,percent of total billed charges,,,,,,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,2363.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2406,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2372.11,,,percent of total billed charges,,,,,,2033.24,,,percent of total billed charges,,,,,,1524.93,,,percent of total billed charges,,,,,,,,,,,,,,,2880.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,3388.73,,,percent of total billed charges,,,,,,1457.15,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3388.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2541.55,,,percent of total billed charges,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3388.73,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3388.73,,,percent of total billed charges,,,,,,1524.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2541.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3388.73,,,fee schedule,,,,,,3388.73,,,percent of total billed charges,,,,,,3388.73,,,percent of total billed charges,,,,,,3388.73,,,percent of total billed charges,,,,,,1626.59,,,percent of total billed charges,,,,,,,,,,,,,,,1999.35,,,percent of total billed charges,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3388.73,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2880.42,,,percent of total billed charges,,,,,,2541.55,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 10.0D,26550,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 10.0D,26550,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 10.5D,26551,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 10.5D,26551,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 11.0D,26552,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 11.0D,26552,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 11.5D,26553,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 11.5D,26553,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 12.0D,26554,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 12.0D,26554,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 12.5D,26555,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 12.5D,26555,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 13.0D,26556,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 13.0D,26556,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 13.5D,26557,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 13.5D,26557,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 14.0D,26558,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 14.0D,26558,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 14.5D,26559,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 14.5D,26559,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 15.0D,26560,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 15.0D,26560,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 15.5D,26561,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 15.5D,26561,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 16.0D,26562,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 16.0D,26562,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 16.5D,26563,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 16.5D,26563,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 17.0D,26564,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 17.0D,26564,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 17.5D,26565,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 17.5D,26565,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 18.0D,26566,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 18.0D,26566,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 18.5D,26567,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 18.5D,26567,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 19.0D,26568,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 19.0D,26568,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 19.5D,26569,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 19.5D,26569,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 20.0D,26570,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 20.0D,26570,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 20.5D,26571,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 20.5D,26571,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 21.0D,26572,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 21.0D,26572,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 21.5D,26573,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 21.5D,26573,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 22.0D,26574,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 22.0D,26574,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 22.5D,26575,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 22.5D,26575,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 23.0D,26576,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 23.0D,26576,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 23.5D,26577,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 23.5D,26577,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 24.0D,26578,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 24.0D,26578,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 24.5D,26579,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 24.5D,26579,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 25.0D,26580,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 25.0D,26580,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 25.5D,26581,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 25.5D,26581,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 26.0D,26582,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 26.0D,26582,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 26.5D,26583,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 26.5D,26583,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 27.0D,26584,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 27.0D,26584,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 27.5D,26585,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 27.5D,26585,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 28.0D,26586,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 28.0D,26586,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 28.5D,26587,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 28.5D,26587,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LENS PC LI61AO 29.0D,26588,CDM,0276,RC,,,,,,inpatient,facility,,,220,220,99,220,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,
LENS PC LI61AO 29.0D,26588,CDM,0276,RC,,,,,,outpatient,facility,,,220,220,41.8,1016,,143,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,103.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,41.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,165,,,percent of total billed charges,,,,,,154,,,percent of total billed charges,,,,,,154,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,,52.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",154,,,percent of total billed charges,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,153.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,156.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,154,,,percent of total billed charges,,,,,,132,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,94.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,220,,,percent of total billed charges,,,,,,99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,,fee schedule,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187,,,percent of total billed charges,,,,,,165,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP DEP HIP SECTOR DURALOC 56MM,26664,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP DEP HIP SECTOR DURALOC 56MM,26664,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRAIN EDS 3 NO VENTRICULAR CATH EXTERNAL  i,26668,CDM,0272,RC,,,,,,inpatient,facility,,,1022,1022,459.9,1022,,,,,,,,,,,,,,,,,,,,868.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,664.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,725.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,715.4,,,percent of total billed charges,,,,,,613.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,868.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1022,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,459.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,868.7,,,percent of total billed charges,,,,,,,,,,,,,,
DRAIN EDS 3 NO VENTRICULAR CATH EXTERNAL  i,26668,CDM,0272,RC,,,,,,outpatient,facility,,,1022,1022,129.72,1022,,664.3,,,percent of total billed charges,,,,,,,,,,,,,,,868.7,,,percent of total billed charges,,,,,,306.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,480.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,194.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,194.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,766.5,,,percent of total billed charges,,,,,,715.4,,,percent of total billed charges,,,,,,715.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,664.3,,,percent of total billed charges,,,,,,245.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",689.85,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1022,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,429.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",715.4,,,percent of total billed charges,,,,,,,,,,,,,,,1022,,,percent of total billed charges,,,,,,712.85,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,725.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,715.4,,,percent of total billed charges,,,,,,613.2,,,percent of total billed charges,,,,,,459.9,,,percent of total billed charges,,,,,,,,,,,,,,,868.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022,,,percent of total billed charges,,,,,,1022,,,percent of total billed charges,,,,,,439.46,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1022,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1022,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.5,,,percent of total billed charges,,,,,,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1022,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1022,,,percent of total billed charges,,,,,,459.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,766.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1022,,,fee schedule,,,,,,1022,,,percent of total billed charges,,,,,,1022,,,percent of total billed charges,,,,,,1022,,,percent of total billed charges,,,,,,490.56,,,percent of total billed charges,,,,,,,,,,,,,,,602.98,,,percent of total billed charges,,,,,,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1022,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,868.7,,,percent of total billed charges,,,,,,766.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE ZEBRA STRT .038 X 3 X 150  i,26671,CDM,0272,RC,,,,,,inpatient,facility,,,187.13,187.13,84.21,187.13,,,,,,,,,,,,,,,,,,,,159.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,130.99,,,percent of total billed charges,,,,,,112.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,159.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,187.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,84.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.06,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE ZEBRA STRT .038 X 3 X 150  i,26671,CDM,0272,RC,,,,,,outpatient,facility,,,187.13,187.13,35.55,1016,,121.63,,,percent of total billed charges,,,,,,,,,,,,,,,159.06,,,percent of total billed charges,,,,,,56.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,87.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,35.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,140.34,,,percent of total billed charges,,,,,,130.99,,,percent of total billed charges,,,,,,130.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,121.63,,,percent of total billed charges,,,,,,44.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",126.31,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,187.13,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,78.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",130.99,,,percent of total billed charges,,,,,,,,,,,,,,,187.13,,,percent of total billed charges,,,,,,130.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,132.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,130.99,,,percent of total billed charges,,,,,,112.28,,,percent of total billed charges,,,,,,84.21,,,percent of total billed charges,,,,,,,,,,,,,,,159.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.13,,,percent of total billed charges,,,,,,187.13,,,percent of total billed charges,,,,,,80.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,187.13,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,187.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.35,,,percent of total billed charges,,,,,,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,187.13,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,187.13,,,percent of total billed charges,,,,,,84.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.13,,,fee schedule,,,,,,187.13,,,percent of total billed charges,,,,,,187.13,,,percent of total billed charges,,,,,,187.13,,,percent of total billed charges,,,,,,89.82,,,percent of total billed charges,,,,,,,,,,,,,,,110.41,,,percent of total billed charges,,,,,,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,187.13,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,159.06,,,percent of total billed charges,,,,,,140.35,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HEMOSTAT SURGICEL NUKNIT 6X9  i,26728,CDM,0272,RC,,,,,,inpatient,facility,,,421.31,421.31,189.59,421.31,,,,,,,,,,,,,,,,,,,,358.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,273.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,294.92,,,percent of total billed charges,,,,,,252.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,358.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,421.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,189.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,358.11,,,percent of total billed charges,,,,,,,,,,,,,,
HEMOSTAT SURGICEL NUKNIT 6X9  i,26728,CDM,0272,RC,,,,,,outpatient,facility,,,421.31,421.31,80.05,1016,,273.85,,,percent of total billed charges,,,,,,,,,,,,,,,358.11,,,percent of total billed charges,,,,,,126.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,80.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,80.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,315.98,,,percent of total billed charges,,,,,,294.92,,,percent of total billed charges,,,,,,294.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,273.85,,,percent of total billed charges,,,,,,101.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",284.38,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,421.31,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,176.95,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",294.92,,,percent of total billed charges,,,,,,,,,,,,,,,421.31,,,percent of total billed charges,,,,,,293.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,299.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,294.92,,,percent of total billed charges,,,,,,252.79,,,percent of total billed charges,,,,,,189.59,,,percent of total billed charges,,,,,,,,,,,,,,,358.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.31,,,percent of total billed charges,,,,,,421.31,,,percent of total billed charges,,,,,,181.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,421.31,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,421.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.98,,,percent of total billed charges,,,,,,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,421.31,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,421.31,,,percent of total billed charges,,,,,,189.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,315.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.31,,,fee schedule,,,,,,421.31,,,percent of total billed charges,,,,,,421.31,,,percent of total billed charges,,,,,,421.31,,,percent of total billed charges,,,,,,202.23,,,percent of total billed charges,,,,,,,,,,,,,,,248.57,,,percent of total billed charges,,,,,,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,421.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,358.11,,,percent of total billed charges,,,,,,315.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEM DEP KNEE PFC SIGMA RET LT SZ4 NC,26907,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEM DEP KNEE PFC SIGMA RET LT SZ4 NC,26907,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INSERT DEP TIBIA PFC CRVD 4 X 10.0,26908,CDM,0278,RC,,,,,,inpatient,facility,,,1127,1127,507.15,1127,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,957.95,,,percent of total billed charges,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,901.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,845.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,619.85,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,681.27,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",800.17,,,percent of total billed charges,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,788.9,,,percent of total billed charges,,,,,,676.2,,,percent of total billed charges,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,957.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,619.85,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1127,,,percent of total billed charges,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,845.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1127,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,507.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,957.95,,,percent of total billed charges,,,,,,732.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
INSERT DEP TIBIA PFC CRVD 4 X 10.0,26908,CDM,0278,RC,,,,,,outpatient,facility,,,1127,1127,129.72,1127,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,957.95,,,percent of total billed charges,,,,,,338.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,214.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,214.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,845.25,,,percent of total billed charges,,,,,,788.9,,,percent of total billed charges,,,,,,788.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,732.55,,,percent of total billed charges,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1127,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,788.9,,,percent of total billed charges,,,,,,619.85,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1127,,,percent of total billed charges,,,,,,786.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,800.17,,,percent of total billed charges,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,788.9,,,percent of total billed charges,,,,,,676.2,,,percent of total billed charges,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,957.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,619.85,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1127,,,percent of total billed charges,,,,,,1127,,,percent of total billed charges,,,,,,619.85,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1127,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1127,,,percent of total billed charges,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,845.25,,,percent of total billed charges,,,,,,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1127,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1127,,,percent of total billed charges,,,,,,507.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,845.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1127,,,fee schedule,,,,,,1127,,,percent of total billed charges,,,,,,1127,,,percent of total billed charges,,,,,,1127,,,percent of total billed charges,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,619.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1127,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,957.95,,,percent of total billed charges,,,,,,845.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATELLA DEP DOME OVAL 38MM NC,26909,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATELLA DEP DOME OVAL 38MM NC,26909,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI IM 4FR 100CM  ORDER SETS OF 5   c,27025,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI IM 4FR 100CM  ORDER SETS OF 5   c,27025,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI RCB 4FR 100CM  ORDER SETS OF 5,27026,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI RCB 4FR 100CM  ORDER SETS OF 5,27026,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI LCB 4FR 100CM  ORDER SETS OF 5,27027,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI LCB 4FR 100CM  ORDER SETS OF 5,27027,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI MPA2 2SH 4FR 100CM  ORDER SETS OF,27028,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI MPA2 2SH 4FR 100CM  ORDER SETS OF,27028,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI AL1 4FR 100CM  ORDER SETS OF 5,27030,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI AL1 4FR 100CM  ORDER SETS OF 5,27030,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI AR2 MOD 4FR 100CM  ORDER SETS OF,27031,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI AR2 MOD 4FR 100CM  ORDER SETS OF,27031,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI AR1 MOD 4FR 100CM  ORDER SETS OF,27032,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI AR1 MOD 4FR 100CM  ORDER SETS OF,27032,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JL6 4FR 100CM  ORDER SETS OF 5,27033,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JL6 4FR 100CM  ORDER SETS OF 5,27033,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JL5 4FR 100CM  ORDER SETS OF 5,27034,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JL5 4FR 100CM  ORDER SETS OF 5,27034,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JL3.5 4FR 100CM  ORDER SETS OF 5,27036,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JL3.5 4FR 100CM  ORDER SETS OF 5,27036,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JR5 4FR 100CM  ORDER SETS OF 5,27038,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JR5 4FR 100CM  ORDER SETS OF 5,27038,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JR4 4FR 100CM  ORDER SETS OF 5,27039,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JR4 4FR 100CM  ORDER SETS OF 5,27039,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JL4 4FR 100CM  ORDER SETS OF 5,27040,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JL4 4FR 100CM  ORDER SETS OF 5,27040,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI JR3.5 4FR 100CM  ORDER SETS OF 5,27041,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI JR3.5 4FR 100CM  ORDER SETS OF 5,27041,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC OXYGEN  DAILY RATE,27092423,CDM,0270,RC,,,,,,inpatient,facility,,,171.36,171.36,77.11,171.36,,,,,,,,,,,,,,,,,,,,145.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119.95,,,percent of total billed charges,,,,,,102.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,145.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,171.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,77.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.66,,,percent of total billed charges,,,,,,,,,,,,,,
HC OXYGEN  DAILY RATE,27092423,CDM,0270,RC,,,,,,outpatient,facility,,,171.36,171.36,32.56,1016,,111.38,,,percent of total billed charges,,,,,,,,,,,,,,,145.66,,,percent of total billed charges,,,,,,51.41,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,80.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,32.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,128.52,,,percent of total billed charges,,,,,,119.95,,,percent of total billed charges,,,,,,119.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,111.38,,,percent of total billed charges,,,,,,41.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",115.67,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,171.36,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,71.97,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,24.65,2.13,103.06,1 through 10,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",119.95,,,percent of total billed charges,,,,,,,,,,,,,,,171.36,,,percent of total billed charges,,,,,,119.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,121.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,119.95,,,percent of total billed charges,,,,,,102.82,,,percent of total billed charges,,,,,,77.11,,,percent of total billed charges,,,,,,,,,,,,,,,145.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.36,,,percent of total billed charges,,,,,,171.36,,,percent of total billed charges,,,,,,73.68,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,171.36,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,171.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.52,,,percent of total billed charges,,,,,,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,171.36,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,171.36,,,percent of total billed charges,,,,,,77.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.36,,,fee schedule,,,,,,171.36,,,percent of total billed charges,,,,,,171.36,,,percent of total billed charges,,,,,,171.36,,,percent of total billed charges,,,,,,82.25,,,percent of total billed charges,,,,,,,,,,,,,,,101.1,,,percent of total billed charges,,,,,,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,171.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,145.66,,,percent of total billed charges,,,,,,128.52,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC HELIOX,27092636,CDM,0270,RC,,,,,,inpatient,facility,,,650.89,650.89,292.9,650.89,,,,,,,,,,,,,,,,,,,,553.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,423.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,455.62,,,percent of total billed charges,,,,,,390.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,553.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,650.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,292.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,553.26,,,percent of total billed charges,,,,,,,,,,,,,,
HC HELIOX,27092636,CDM,0270,RC,,,,,,outpatient,facility,,,650.89,650.89,123.67,1016,,423.08,,,percent of total billed charges,,,,,,,,,,,,,,,553.26,,,percent of total billed charges,,,,,,195.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,305.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,123.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,123.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,488.17,,,percent of total billed charges,,,,,,455.62,,,percent of total billed charges,,,,,,455.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,423.08,,,percent of total billed charges,,,,,,156.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",439.35,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,650.89,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,273.37,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",455.62,,,percent of total billed charges,,,,,,,,,,,,,,,650.89,,,percent of total billed charges,,,,,,454,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,462.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,455.62,,,percent of total billed charges,,,,,,390.53,,,percent of total billed charges,,,,,,292.9,,,percent of total billed charges,,,,,,,,,,,,,,,553.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.89,,,percent of total billed charges,,,,,,650.89,,,percent of total billed charges,,,,,,279.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,650.89,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,650.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.17,,,percent of total billed charges,,,,,,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.89,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,650.89,,,percent of total billed charges,,,,,,292.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,650.89,,,fee schedule,,,,,,650.89,,,percent of total billed charges,,,,,,650.89,,,percent of total billed charges,,,,,,650.89,,,percent of total billed charges,,,,,,312.43,,,percent of total billed charges,,,,,,,,,,,,,,,384.03,,,percent of total billed charges,,,,,,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,650.89,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,553.26,,,percent of total billed charges,,,,,,488.17,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC PLATELET FILTER PL100,27098057,CDM,0270,RC,,,,,,inpatient,facility,,,243.71,243.71,109.67,243.71,,,,,,,,,,,,,,,,,,,,207.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,170.6,,,percent of total billed charges,,,,,,146.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,207.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,243.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,109.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.15,,,percent of total billed charges,,,,,,,,,,,,,,
HC PLATELET FILTER PL100,27098057,CDM,0270,RC,,,,,,outpatient,facility,,,243.71,243.71,46.3,1016,,158.41,,,percent of total billed charges,,,,,,,,,,,,,,,207.15,,,percent of total billed charges,,,,,,73.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,114.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,46.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,182.78,,,percent of total billed charges,,,,,,170.6,,,percent of total billed charges,,,,,,170.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,158.41,,,percent of total billed charges,,,,,,58.49,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",164.5,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,243.71,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,102.36,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",170.6,,,percent of total billed charges,,,,,,,,,,,,,,,243.71,,,percent of total billed charges,,,,,,169.99,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,173.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,170.6,,,percent of total billed charges,,,,,,146.23,,,percent of total billed charges,,,,,,109.67,,,percent of total billed charges,,,,,,,,,,,,,,,207.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.71,,,percent of total billed charges,,,,,,243.71,,,percent of total billed charges,,,,,,104.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,243.71,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,243.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.78,,,percent of total billed charges,,,,,,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,243.71,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,243.71,,,percent of total billed charges,,,,,,109.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,182.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.71,,,fee schedule,,,,,,243.71,,,percent of total billed charges,,,,,,243.71,,,percent of total billed charges,,,,,,243.71,,,percent of total billed charges,,,,,,116.98,,,percent of total billed charges,,,,,,,,,,,,,,,143.79,,,percent of total billed charges,,,,,,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,243.71,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,207.15,,,percent of total billed charges,,,,,,182.78,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT STR ORAL 1.3 X 53,27133,CDM,0272,RC,,,,,,inpatient,facility,,,395.04,395.04,177.77,395.04,,,,,,,,,,,,,,,,,,,,335.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,276.53,,,percent of total billed charges,,,,,,237.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,335.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,395.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,177.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,335.78,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT STR ORAL 1.3 X 53,27133,CDM,0272,RC,,,,,,outpatient,facility,,,395.04,395.04,75.06,1016,,256.78,,,percent of total billed charges,,,,,,,,,,,,,,,335.78,,,percent of total billed charges,,,,,,118.51,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,185.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,75.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,296.28,,,percent of total billed charges,,,,,,276.53,,,percent of total billed charges,,,,,,276.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,256.78,,,percent of total billed charges,,,,,,94.81,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",266.65,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,395.04,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,165.92,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",276.53,,,percent of total billed charges,,,,,,,,,,,,,,,395.04,,,percent of total billed charges,,,,,,275.54,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,280.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,276.53,,,percent of total billed charges,,,,,,237.02,,,percent of total billed charges,,,,,,177.77,,,percent of total billed charges,,,,,,,,,,,,,,,335.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.04,,,percent of total billed charges,,,,,,395.04,,,percent of total billed charges,,,,,,169.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,395.04,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,395.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.28,,,percent of total billed charges,,,,,,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,395.04,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,395.04,,,percent of total billed charges,,,,,,177.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.04,,,fee schedule,,,,,,395.04,,,percent of total billed charges,,,,,,395.04,,,percent of total billed charges,,,,,,395.04,,,percent of total billed charges,,,,,,189.62,,,percent of total billed charges,,,,,,,,,,,,,,,233.07,,,percent of total billed charges,,,,,,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,395.04,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,335.78,,,percent of total billed charges,,,,,,296.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT STR ORAL 1.0 X 50,27134,CDM,0272,RC,,,,,,inpatient,facility,,,404.25,404.25,181.91,404.25,,,,,,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.98,,,percent of total billed charges,,,,,,242.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,181.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT STR ORAL 1.0 X 50,27134,CDM,0272,RC,,,,,,outpatient,facility,,,404.25,404.25,76.81,1016,,262.76,,,percent of total billed charges,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,121.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,76.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,76.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,303.19,,,percent of total billed charges,,,,,,282.98,,,percent of total billed charges,,,,,,282.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,262.76,,,percent of total billed charges,,,,,,97.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",272.87,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,404.25,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,169.78,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",282.97,,,percent of total billed charges,,,,,,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,281.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,287.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.98,,,percent of total billed charges,,,,,,242.55,,,percent of total billed charges,,,,,,181.91,,,percent of total billed charges,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,404.25,,,percent of total billed charges,,,,,,173.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,404.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.19,,,percent of total billed charges,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,404.25,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,404.25,,,percent of total billed charges,,,,,,181.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,,fee schedule,,,,,,404.25,,,percent of total billed charges,,,,,,404.25,,,percent of total billed charges,,,,,,404.25,,,percent of total billed charges,,,,,,194.04,,,percent of total billed charges,,,,,,,,,,,,,,,238.51,,,percent of total billed charges,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,343.61,,,percent of total billed charges,,,,,,303.19,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT STR ORAL 1.0 X 46,27135,CDM,0272,RC,,,,,,inpatient,facility,,,404.25,404.25,181.91,404.25,,,,,,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.98,,,percent of total billed charges,,,,,,242.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,181.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT STR ORAL 1.0 X 46,27135,CDM,0272,RC,,,,,,outpatient,facility,,,404.25,404.25,76.81,1016,,262.76,,,percent of total billed charges,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,121.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,76.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,76.81,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,303.19,,,percent of total billed charges,,,,,,282.98,,,percent of total billed charges,,,,,,282.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,262.76,,,percent of total billed charges,,,,,,97.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",272.87,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,404.25,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,169.78,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",282.97,,,percent of total billed charges,,,,,,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,281.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,287.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,282.98,,,percent of total billed charges,,,,,,242.55,,,percent of total billed charges,,,,,,181.91,,,percent of total billed charges,,,,,,,,,,,,,,,343.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,404.25,,,percent of total billed charges,,,,,,173.83,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,404.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.19,,,percent of total billed charges,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,404.25,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,404.25,,,percent of total billed charges,,,,,,181.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.25,,,fee schedule,,,,,,404.25,,,percent of total billed charges,,,,,,404.25,,,percent of total billed charges,,,,,,404.25,,,percent of total billed charges,,,,,,194.04,,,percent of total billed charges,,,,,,,,,,,,,,,238.51,,,percent of total billed charges,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,404.25,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,343.61,,,percent of total billed charges,,,,,,303.19,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
BASKET ZERO TIP STONE RETRIEVAL 4W O TIP NITINOL 3,27139,CDM,0272,RC,,,,,,inpatient,facility,,,592.06,592.06,266.43,592.06,,,,,,,,,,,,,,,,,,,,503.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,444.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,414.44,,,percent of total billed charges,,,,,,355.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,503.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,444.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,592.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,266.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,503.25,,,percent of total billed charges,,,,,,,,,,,,,,
BASKET ZERO TIP STONE RETRIEVAL 4W O TIP NITINOL 3,27139,CDM,0272,RC,,,,,,outpatient,facility,,,592.06,592.06,112.49,1016,,384.84,,,percent of total billed charges,,,,,,,,,,,,,,,503.25,,,percent of total billed charges,,,,,,177.62,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,278.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,112.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,112.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,444.04,,,percent of total billed charges,,,,,,414.44,,,percent of total billed charges,,,,,,414.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,384.84,,,percent of total billed charges,,,,,,142.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",399.64,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,592.06,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,248.67,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",414.44,,,percent of total billed charges,,,,,,,,,,,,,,,592.06,,,percent of total billed charges,,,,,,412.96,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,420.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,414.44,,,percent of total billed charges,,,,,,355.24,,,percent of total billed charges,,,,,,266.43,,,percent of total billed charges,,,,,,,,,,,,,,,503.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.06,,,percent of total billed charges,,,,,,592.06,,,percent of total billed charges,,,,,,254.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,592.06,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,592.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,444.04,,,percent of total billed charges,,,,,,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,592.06,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,592.06,,,percent of total billed charges,,,,,,266.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,444.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,592.06,,,fee schedule,,,,,,592.06,,,percent of total billed charges,,,,,,592.06,,,percent of total billed charges,,,,,,592.06,,,percent of total billed charges,,,,,,284.19,,,percent of total billed charges,,,,,,,,,,,,,,,349.32,,,percent of total billed charges,,,,,,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,592.06,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,503.25,,,percent of total billed charges,,,,,,444.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SET DILATOR SHEATH 8 10  i,27141,CDM,0272,RC,,,,,,inpatient,facility,,,168.14,168.14,75.66,168.14,,,,,,,,,,,,,,,,,,,,142.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.7,,,percent of total billed charges,,,,,,100.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,142.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,75.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.92,,,percent of total billed charges,,,,,,,,,,,,,,
SET DILATOR SHEATH 8 10  i,27141,CDM,0272,RC,,,,,,outpatient,facility,,,168.14,168.14,31.95,1016,,109.29,,,percent of total billed charges,,,,,,,,,,,,,,,142.92,,,percent of total billed charges,,,,,,50.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,31.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,31.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,126.1,,,percent of total billed charges,,,,,,117.7,,,percent of total billed charges,,,,,,117.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.29,,,percent of total billed charges,,,,,,40.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",113.49,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168.14,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.62,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.7,,,percent of total billed charges,,,,,,,,,,,,,,,168.14,,,percent of total billed charges,,,,,,117.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,117.7,,,percent of total billed charges,,,,,,100.88,,,percent of total billed charges,,,,,,75.66,,,percent of total billed charges,,,,,,,,,,,,,,,142.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.14,,,percent of total billed charges,,,,,,168.14,,,percent of total billed charges,,,,,,72.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,168.14,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,168.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.1,,,percent of total billed charges,,,,,,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,168.14,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,168.14,,,percent of total billed charges,,,,,,75.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.14,,,fee schedule,,,,,,168.14,,,percent of total billed charges,,,,,,168.14,,,percent of total billed charges,,,,,,168.14,,,percent of total billed charges,,,,,,80.71,,,percent of total billed charges,,,,,,,,,,,,,,,99.2,,,percent of total billed charges,,,,,,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,168.14,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,142.92,,,percent of total billed charges,,,,,,126.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH PERITONEAL MONCRIEF PEDI 62.5CM  i,27144,CDM,0278,RC,,,,,,inpatient,facility,,,368.51,368.51,165.83,368.51,,,,,,,,,,,,,,,,,,,,313.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,276.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.76,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",261.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.96,,,percent of total billed charges,,,,,,221.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,313.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,165.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,313.23,,,percent of total billed charges,,,,,,239.53,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CATH PERITONEAL MONCRIEF PEDI 62.5CM  i,27144,CDM,0278,RC,,,,,,outpatient,facility,,,368.51,368.51,70.02,368.51,,239.53,,,percent of total billed charges,,,,,,,,,,,,,,,313.23,,,percent of total billed charges,,,,,,110.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,173.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.68,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,70.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,70.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,202.68,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,202.68,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,202.68,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,276.38,,,percent of total billed charges,,,,,,257.96,,,percent of total billed charges,,,,,,257.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,239.53,,,percent of total billed charges,,,,,,88.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,368.51,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,154.77,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",257.96,,,percent of total billed charges,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,257.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,261.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,257.96,,,percent of total billed charges,,,,,,221.11,,,percent of total billed charges,,,,,,165.83,,,percent of total billed charges,,,,,,,,,,,,,,,313.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,368.51,,,percent of total billed charges,,,,,,158.46,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.38,,,percent of total billed charges,,,,,,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,368.51,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,368.51,,,percent of total billed charges,,,,,,165.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,276.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,,fee schedule,,,,,,368.51,,,percent of total billed charges,,,,,,368.51,,,percent of total billed charges,,,,,,368.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,368.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,313.23,,,percent of total billed charges,,,,,,276.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT VASC HEMASHIELD BIF 12 X 6 X 40,27156,CDM,0278,RC,,,,,,inpatient,facility,,,1513.08,1513.08,680.89,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1210.46,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1134.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,914.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,983.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT VASC HEMASHIELD BIF 12 X 6 X 40,27156,CDM,0278,RC,,,,,,outpatient,facility,,,1513.08,1513.08,129.72,1513.08,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1286.12,,,percent of total billed charges,,,,,,453.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,287.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1134.81,,,percent of total billed charges,,,,,,1059.16,,,percent of total billed charges,,,,,,1059.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,983.5,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1513.08,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,832.19,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1055.37,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1074.29,,,percent of total billed charges,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1059.16,,,percent of total billed charges,,,,,,907.85,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1286.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,832.19,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1513.08,,,percent of total billed charges,,,,,,680.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1134.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1513.08,,,fee schedule,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,1513.08,,,percent of total billed charges,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,832.19,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1513.08,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1286.12,,,percent of total billed charges,,,,,,1134.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEAD MED CAPSURE SP NOVUS 58CM 5092,27158,CDM,0275,RC,,,,,,inpatient,facility,,,850,850,382.5,850,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,
LEAD MED CAPSURE SP NOVUS 58CM 5092,27158,CDM,0275,RC,,,,,,outpatient,facility,,,850,850,129.72,850,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,255,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,161.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,637.5,,,percent of total billed charges,,,,,,595,,,percent of total billed charges,,,,,,595,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,552.5,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,850,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,467.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,592.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,603.5,,,percent of total billed charges,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,595,,,percent of total billed charges,,,,,,510,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,467.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,,percent of total billed charges,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,850,,,percent of total billed charges,,,,,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,467.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,850,,,fee schedule,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,850,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,722.5,,,percent of total billed charges,,,,,,637.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN QC 3 FLUTE 4.0 X 195,27169,CDM,0272,RC,,,,,,inpatient,facility,,,522.23,522.23,235,522.23,,,,,,,,,,,,,,,,,,,,443.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,370.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,365.56,,,percent of total billed charges,,,,,,313.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,443.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,522.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,235,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,443.9,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN QC 3 FLUTE 4.0 X 195,27169,CDM,0272,RC,,,,,,outpatient,facility,,,522.23,522.23,99.22,1016,,339.45,,,percent of total billed charges,,,,,,,,,,,,,,,443.9,,,percent of total billed charges,,,,,,156.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,245.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,99.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,99.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,391.68,,,percent of total billed charges,,,,,,365.56,,,percent of total billed charges,,,,,,365.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,339.45,,,percent of total billed charges,,,,,,125.34,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",352.51,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,522.23,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.34,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",365.56,,,percent of total billed charges,,,,,,,,,,,,,,,522.23,,,percent of total billed charges,,,,,,364.26,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,370.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,365.56,,,percent of total billed charges,,,,,,313.34,,,percent of total billed charges,,,,,,235,,,percent of total billed charges,,,,,,,,,,,,,,,443.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.23,,,percent of total billed charges,,,,,,522.23,,,percent of total billed charges,,,,,,224.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,522.23,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,522.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.67,,,percent of total billed charges,,,,,,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,522.23,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,522.23,,,percent of total billed charges,,,,,,235,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,522.23,,,fee schedule,,,,,,522.23,,,percent of total billed charges,,,,,,522.23,,,percent of total billed charges,,,,,,522.23,,,percent of total billed charges,,,,,,250.67,,,percent of total billed charges,,,,,,,,,,,,,,,308.12,,,percent of total billed charges,,,,,,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,522.23,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,443.9,,,percent of total billed charges,,,,,,391.67,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
INTRO MULTIPURPOSE 9FR PLVN 9.0 38 24 VAD5 CVI  i,27175,CDM,0272,RC,,,,,,inpatient,facility,,,514.46,514.46,231.51,514.46,,,,,,,,,,,,,,,,,,,,437.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,360.12,,,percent of total billed charges,,,,,,308.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,437.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,514.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,514.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,231.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.29,,,percent of total billed charges,,,,,,,,,,,,,,
INTRO MULTIPURPOSE 9FR PLVN 9.0 38 24 VAD5 CVI  i,27175,CDM,0272,RC,,,,,,outpatient,facility,,,514.46,514.46,97.75,1016,,334.4,,,percent of total billed charges,,,,,,,,,,,,,,,437.29,,,percent of total billed charges,,,,,,154.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,97.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,97.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,385.84,,,percent of total billed charges,,,,,,360.12,,,percent of total billed charges,,,,,,360.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,334.4,,,percent of total billed charges,,,,,,123.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",347.26,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,514.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,216.07,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",360.12,,,percent of total billed charges,,,,,,,,,,,,,,,514.46,,,percent of total billed charges,,,,,,358.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,365.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,360.12,,,percent of total billed charges,,,,,,308.68,,,percent of total billed charges,,,,,,231.51,,,percent of total billed charges,,,,,,,,,,,,,,,437.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,514.46,,,percent of total billed charges,,,,,,514.46,,,percent of total billed charges,,,,,,221.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,514.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,514.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.84,,,percent of total billed charges,,,,,,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,514.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,514.46,,,percent of total billed charges,,,,,,231.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,514.46,,,fee schedule,,,,,,514.46,,,percent of total billed charges,,,,,,514.46,,,percent of total billed charges,,,,,,514.46,,,percent of total billed charges,,,,,,246.94,,,percent of total billed charges,,,,,,,,,,,,,,,303.53,,,percent of total billed charges,,,,,,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,514.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,437.29,,,percent of total billed charges,,,,,,385.85,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T LOCK 5.0 X 25,27177,CDM,0278,RC,,,,,,inpatient,facility,,,169,169,76.05,169,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,126.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.16,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,109.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T LOCK 5.0 X 25,27177,CDM,0278,RC,,,,,,outpatient,facility,,,169,169,32.11,169,,109.85,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,50.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,79.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,32.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.95,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,126.75,,,percent of total billed charges,,,,,,118.3,,,percent of total billed charges,,,,,,118.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,109.85,,,percent of total billed charges,,,,,,40.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,169,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",118.3,,,percent of total billed charges,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,117.88,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,119.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,118.3,,,percent of total billed charges,,,,,,101.4,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,72.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,169,,,percent of total billed charges,,,,,,76.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,fee schedule,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,169,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.65,,,percent of total billed charges,,,,,,126.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI R T HUM LOCK SS 4.0 X 52,27187,CDM,0278,RC,,,,,,inpatient,facility,,,162.72,162.72,73.22,162.72,,,,,,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,122.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.36,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",115.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.9,,,percent of total billed charges,,,,,,97.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,105.77,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI R T HUM LOCK SS 4.0 X 52,27187,CDM,0278,RC,,,,,,outpatient,facility,,,162.72,162.72,30.92,162.72,,105.77,,,percent of total billed charges,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,48.82,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,76.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,30.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,89.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,89.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,89.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,122.04,,,percent of total billed charges,,,,,,113.9,,,percent of total billed charges,,,,,,113.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,105.77,,,percent of total billed charges,,,,,,39.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,162.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.34,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",113.9,,,percent of total billed charges,,,,,,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,113.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,115.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.9,,,percent of total billed charges,,,,,,97.63,,,percent of total billed charges,,,,,,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,138.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,162.72,,,percent of total billed charges,,,,,,69.97,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,162.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.04,,,percent of total billed charges,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,162.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.72,,,percent of total billed charges,,,,,,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,,fee schedule,,,,,,162.72,,,percent of total billed charges,,,,,,162.72,,,percent of total billed charges,,,,,,162.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,162.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,138.31,,,percent of total billed charges,,,,,,122.04,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GWIRE SYN FOR TI FEM NL 3.2MM,27195,CDM,0272,RC,,,,,,inpatient,facility,,,395.81,395.81,178.11,395.81,,,,,,,,,,,,,,,,,,,,336.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,277.07,,,percent of total billed charges,,,,,,237.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,336.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,395.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,178.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.44,,,percent of total billed charges,,,,,,,,,,,,,,
GWIRE SYN FOR TI FEM NL 3.2MM,27195,CDM,0272,RC,,,,,,outpatient,facility,,,395.81,395.81,75.2,1016,,257.28,,,percent of total billed charges,,,,,,,,,,,,,,,336.44,,,percent of total billed charges,,,,,,118.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,186.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,75.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,296.86,,,percent of total billed charges,,,,,,277.07,,,percent of total billed charges,,,,,,277.07,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,257.28,,,percent of total billed charges,,,,,,94.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",267.17,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,395.81,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,166.24,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",277.07,,,percent of total billed charges,,,,,,,,,,,,,,,395.81,,,percent of total billed charges,,,,,,276.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,281.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,277.07,,,percent of total billed charges,,,,,,237.49,,,percent of total billed charges,,,,,,178.11,,,percent of total billed charges,,,,,,,,,,,,,,,336.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.81,,,percent of total billed charges,,,,,,395.81,,,percent of total billed charges,,,,,,170.2,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,395.81,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,395.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.86,,,percent of total billed charges,,,,,,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,395.81,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,395.81,,,percent of total billed charges,,,,,,178.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.81,,,fee schedule,,,,,,395.81,,,percent of total billed charges,,,,,,395.81,,,percent of total billed charges,,,,,,395.81,,,percent of total billed charges,,,,,,189.99,,,percent of total billed charges,,,,,,,,,,,,,,,233.53,,,percent of total billed charges,,,,,,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,395.81,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,336.44,,,percent of total billed charges,,,,,,296.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD SYN REAMING STRT BALL STRL 3.0 X 950  i,27199,CDM,0272,RC,,,,,,inpatient,facility,,,715.75,715.75,322.09,715.75,,,,,,,,,,,,,,,,,,,,608.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,536.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,501.02,,,percent of total billed charges,,,,,,429.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,608.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,536.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,715.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,322.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,608.39,,,percent of total billed charges,,,,,,,,,,,,,,
ROD SYN REAMING STRT BALL STRL 3.0 X 950  i,27199,CDM,0272,RC,,,,,,outpatient,facility,,,715.75,715.75,129.72,1016,,465.24,,,percent of total billed charges,,,,,,,,,,,,,,,608.39,,,percent of total billed charges,,,,,,214.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,336.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,135.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,536.81,,,percent of total billed charges,,,,,,501.02,,,percent of total billed charges,,,,,,501.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,465.24,,,percent of total billed charges,,,,,,171.78,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",483.13,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,715.75,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,300.62,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",501.02,,,percent of total billed charges,,,,,,,,,,,,,,,715.75,,,percent of total billed charges,,,,,,499.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,508.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,501.02,,,percent of total billed charges,,,,,,429.45,,,percent of total billed charges,,,,,,322.09,,,percent of total billed charges,,,,,,,,,,,,,,,608.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.75,,,percent of total billed charges,,,,,,715.75,,,percent of total billed charges,,,,,,307.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,715.75,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,715.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,536.81,,,percent of total billed charges,,,,,,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,715.75,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,715.75,,,percent of total billed charges,,,,,,322.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,536.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.75,,,fee schedule,,,,,,715.75,,,percent of total billed charges,,,,,,715.75,,,percent of total billed charges,,,,,,715.75,,,percent of total billed charges,,,,,,343.56,,,percent of total billed charges,,,,,,,,,,,,,,,422.29,,,percent of total billed charges,,,,,,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,715.75,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,608.39,,,percent of total billed charges,,,,,,536.81,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC ADHESIVE TISSUE INDERMIL,27227283,CDM,0272,RC,,,,,,inpatient,facility,,,74.53,74.53,33.54,74.53,,,,,,,,,,,,,,,,,,,,63.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.17,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,74.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,33.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.35,,,percent of total billed charges,,,,,,,,,,,,,,
HC ADHESIVE TISSUE INDERMIL,27227283,CDM,0272,RC,,,,,,outpatient,facility,,,74.53,74.53,14.16,1016,,48.44,,,percent of total billed charges,,,,,,,,,,,,,,,63.35,,,percent of total billed charges,,,,,,22.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,55.9,,,percent of total billed charges,,,,,,52.17,,,percent of total billed charges,,,,,,52.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,48.44,,,percent of total billed charges,,,,,,17.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",50.31,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,74.53,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,31.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",52.17,,,percent of total billed charges,,,,,,,,,,,,,,,74.53,,,percent of total billed charges,,,,,,51.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,52.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.17,,,percent of total billed charges,,,,,,44.72,,,percent of total billed charges,,,,,,33.54,,,percent of total billed charges,,,,,,,,,,,,,,,63.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.53,,,percent of total billed charges,,,,,,74.53,,,percent of total billed charges,,,,,,32.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,74.53,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,74.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.9,,,percent of total billed charges,,,,,,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.53,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,74.53,,,percent of total billed charges,,,,,,33.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.53,,,fee schedule,,,,,,74.53,,,percent of total billed charges,,,,,,74.53,,,percent of total billed charges,,,,,,74.53,,,percent of total billed charges,,,,,,35.77,,,percent of total billed charges,,,,,,,,,,,,,,,43.97,,,percent of total billed charges,,,,,,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,74.53,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,63.35,,,percent of total billed charges,,,,,,55.9,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DERMABOND SKIN ADH TOP HI VISC,27246685,CDM,0272,RC,,,,,,inpatient,facility,,,55.38,55.38,24.92,55.38,,,,,,,,,,,,,,,,,,,,47.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,38.77,,,percent of total billed charges,,,,,,33.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,47.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,55.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.07,,,percent of total billed charges,,,,,,,,,,,,,,
HC DERMABOND SKIN ADH TOP HI VISC,27246685,CDM,0272,RC,,,,,,outpatient,facility,,,55.38,55.38,10.52,1016,,36,,,percent of total billed charges,,,,,,,,,,,,,,,47.07,,,percent of total billed charges,,,,,,16.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,26.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,10.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,10.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,41.53,,,percent of total billed charges,,,,,,38.77,,,percent of total billed charges,,,,,,38.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,36,,,percent of total billed charges,,,,,,13.29,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",37.38,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,55.38,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",38.77,,,percent of total billed charges,,,,,,,,,,,,,,,55.38,,,percent of total billed charges,,,,,,38.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,39.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,38.77,,,percent of total billed charges,,,,,,33.23,,,percent of total billed charges,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,47.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.38,,,percent of total billed charges,,,,,,55.38,,,percent of total billed charges,,,,,,23.81,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,55.38,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,55.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.54,,,percent of total billed charges,,,,,,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.38,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,55.38,,,percent of total billed charges,,,,,,24.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.38,,,fee schedule,,,,,,55.38,,,percent of total billed charges,,,,,,55.38,,,percent of total billed charges,,,,,,55.38,,,percent of total billed charges,,,,,,26.58,,,percent of total billed charges,,,,,,,,,,,,,,,32.67,,,percent of total billed charges,,,,,,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,55.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,47.07,,,percent of total billed charges,,,,,,41.53,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC CATH BALL SOS BAKRI TAMPONADE,27250917,CDM,0272,RC,,,,,,inpatient,facility,,,530.35,530.35,238.66,530.35,,,,,,,,,,,,,,,,,,,,450.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,344.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,376.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,,,,318.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,450.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,530.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,238.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,450.8,,,percent of total billed charges,,,,,,,,,,,,,,
HC CATH BALL SOS BAKRI TAMPONADE,27250917,CDM,0272,RC,,,,,,outpatient,facility,,,530.35,530.35,100.77,1016,,344.73,,,percent of total billed charges,,,,,,,,,,,,,,,450.8,,,percent of total billed charges,,,,,,159.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,249.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,100.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,100.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,397.77,,,percent of total billed charges,,,,,,371.25,,,percent of total billed charges,,,,,,371.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,344.73,,,percent of total billed charges,,,,,,127.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",357.99,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,530.35,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,222.75,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",371.25,,,percent of total billed charges,,,,,,,,,,,,,,,530.35,,,percent of total billed charges,,,,,,369.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,376.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,371.25,,,percent of total billed charges,,,,,,318.21,,,percent of total billed charges,,,,,,238.66,,,percent of total billed charges,,,,,,,,,,,,,,,450.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.35,,,percent of total billed charges,,,,,,530.35,,,percent of total billed charges,,,,,,228.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,530.35,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,530.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.76,,,percent of total billed charges,,,,,,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,530.35,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,530.35,,,percent of total billed charges,,,,,,238.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,397.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,530.35,,,fee schedule,,,,,,530.35,,,percent of total billed charges,,,,,,530.35,,,percent of total billed charges,,,,,,530.35,,,percent of total billed charges,,,,,,254.57,,,percent of total billed charges,,,,,,,,,,,,,,,312.91,,,percent of total billed charges,,,,,,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,530.35,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,450.8,,,percent of total billed charges,,,,,,397.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST 2.7 X 10,27255,CDM,0278,RC,,,,,,inpatient,facility,,,99.76,99.76,44.89,99.76,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,64.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST 2.7 X 10,27255,CDM,0278,RC,,,,,,outpatient,facility,,,99.76,99.76,18.95,138.8,,64.84,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.82,,,percent of total billed charges,,,,,,69.83,,,percent of total billed charges,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,64.84,,,percent of total billed charges,,,,,,23.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,99.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,69.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,42.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,fee schedule,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84.8,,,percent of total billed charges,,,,,,74.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST 2.7 X 12,27256,CDM,0278,RC,,,,,,inpatient,facility,,,99.76,99.76,44.89,99.76,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,64.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST 2.7 X 12,27256,CDM,0278,RC,,,,,,outpatient,facility,,,99.76,99.76,18.95,138.8,,64.84,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.82,,,percent of total billed charges,,,,,,69.83,,,percent of total billed charges,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,64.84,,,percent of total billed charges,,,,,,23.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,99.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,69.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,42.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,fee schedule,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84.8,,,percent of total billed charges,,,,,,74.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST 2.7 X 14,27257,CDM,0278,RC,,,,,,inpatient,facility,,,99.76,99.76,44.89,99.76,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,64.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST 2.7 X 14,27257,CDM,0278,RC,,,,,,outpatient,facility,,,99.76,99.76,18.95,138.8,,64.84,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.82,,,percent of total billed charges,,,,,,69.83,,,percent of total billed charges,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,64.84,,,percent of total billed charges,,,,,,23.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,99.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,69.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,42.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,fee schedule,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84.8,,,percent of total billed charges,,,,,,74.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST 2.7 X 16,27258,CDM,0278,RC,,,,,,inpatient,facility,,,99.76,99.76,44.89,99.76,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,64.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST 2.7 X 16,27258,CDM,0278,RC,,,,,,outpatient,facility,,,99.76,99.76,18.95,138.8,,64.84,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.82,,,percent of total billed charges,,,,,,69.83,,,percent of total billed charges,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,64.84,,,percent of total billed charges,,,,,,23.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,99.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,69.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,42.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,fee schedule,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84.8,,,percent of total billed charges,,,,,,74.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST 2.7 X 18,27259,CDM,0278,RC,,,,,,inpatient,facility,,,99.76,99.76,44.89,99.76,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,64.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST 2.7 X 18,27259,CDM,0278,RC,,,,,,outpatient,facility,,,99.76,99.76,18.95,138.8,,64.84,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.82,,,percent of total billed charges,,,,,,69.83,,,percent of total billed charges,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,64.84,,,percent of total billed charges,,,,,,23.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,99.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,69.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,42.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,fee schedule,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84.8,,,percent of total billed charges,,,,,,74.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST 2.7 X 20,27260,CDM,0278,RC,,,,,,inpatient,facility,,,99.76,99.76,44.89,99.76,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,64.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST 2.7 X 20,27260,CDM,0278,RC,,,,,,outpatient,facility,,,99.76,99.76,18.95,138.8,,64.84,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.82,,,percent of total billed charges,,,,,,69.83,,,percent of total billed charges,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,64.84,,,percent of total billed charges,,,,,,23.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,99.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,69.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,42.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,fee schedule,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84.8,,,percent of total billed charges,,,,,,74.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST 2.7 X 22,27261,CDM,0278,RC,,,,,,inpatient,facility,,,99.76,99.76,44.89,99.76,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,64.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST 2.7 X 22,27261,CDM,0278,RC,,,,,,outpatient,facility,,,99.76,99.76,18.95,138.8,,64.84,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.82,,,percent of total billed charges,,,,,,69.83,,,percent of total billed charges,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,64.84,,,percent of total billed charges,,,,,,23.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,99.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,69.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,42.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,fee schedule,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84.8,,,percent of total billed charges,,,,,,74.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CORT MINI TI ST 2.7 X 24,27262,CDM,0278,RC,,,,,,inpatient,facility,,,99.76,99.76,44.89,99.76,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.81,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.3,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,64.84,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CORT MINI TI ST 2.7 X 24,27262,CDM,0278,RC,,,,,,outpatient,facility,,,99.76,99.76,18.95,138.8,,64.84,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,29.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.82,,,percent of total billed charges,,,,,,69.83,,,percent of total billed charges,,,,,,69.83,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,64.84,,,percent of total billed charges,,,,,,23.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,99.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.9,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.83,,,percent of total billed charges,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,69.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.83,,,percent of total billed charges,,,,,,59.86,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,84.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,42.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,99.76,,,percent of total billed charges,,,,,,44.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,,fee schedule,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,99.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,99.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,84.8,,,percent of total billed charges,,,,,,74.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SUTURES,27290431,CDM,0272,RC,,,,,,inpatient,facility,,,28.11,28.11,12.65,28.11,,,,,,,,,,,,,,,,,,,,23.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,19.68,,,percent of total billed charges,,,,,,16.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.89,,,percent of total billed charges,,,,,,,,,,,,,,
HC SUTURES,27290431,CDM,0272,RC,,,,,,outpatient,facility,,,28.11,28.11,5.34,1016,,18.27,,,percent of total billed charges,,,,,,,,,,,,,,,23.89,,,percent of total billed charges,,,,,,8.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.08,,,percent of total billed charges,,,,,,19.68,,,percent of total billed charges,,,,,,19.68,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,6.75,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",18.97,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,28.11,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,11.81,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.68,,,percent of total billed charges,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,19.61,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,19.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,19.68,,,percent of total billed charges,,,,,,16.87,,,percent of total billed charges,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,23.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,28.11,,,percent of total billed charges,,,,,,12.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,28.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.11,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,28.11,,,percent of total billed charges,,,,,,12.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.11,,,fee schedule,,,,,,28.11,,,percent of total billed charges,,,,,,28.11,,,percent of total billed charges,,,,,,28.11,,,percent of total billed charges,,,,,,13.49,,,percent of total billed charges,,,,,,,,,,,,,,,16.58,,,percent of total billed charges,,,,,,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,28.11,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.89,,,percent of total billed charges,,,,,,21.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC STAPLER,27290432,CDM,0272,RC,,,,,,inpatient,facility,,,36.48,36.48,16.42,36.48,,,,,,,,,,,,,,,,,,,,31.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,21.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,31.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,36.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,16.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.01,,,percent of total billed charges,,,,,,,,,,,,,,
HC STAPLER,27290432,CDM,0272,RC,,,,,,outpatient,facility,,,36.48,36.48,6.93,1016,,23.71,,,percent of total billed charges,,,,,,,,,,,,,,,31.01,,,percent of total billed charges,,,,,,10.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,6.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,27.36,,,percent of total billed charges,,,,,,25.54,,,percent of total billed charges,,,,,,25.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,23.71,,,percent of total billed charges,,,,,,8.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",24.62,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,36.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,15.32,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",25.54,,,percent of total billed charges,,,,,,,,,,,,,,,36.48,,,percent of total billed charges,,,,,,25.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,25.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,25.54,,,percent of total billed charges,,,,,,21.89,,,percent of total billed charges,,,,,,16.42,,,percent of total billed charges,,,,,,,,,,,,,,,31.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.48,,,percent of total billed charges,,,,,,36.48,,,percent of total billed charges,,,,,,15.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,36.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,36.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.36,,,percent of total billed charges,,,,,,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,36.48,,,percent of total billed charges,,,,,,16.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.48,,,fee schedule,,,,,,36.48,,,percent of total billed charges,,,,,,36.48,,,percent of total billed charges,,,,,,36.48,,,percent of total billed charges,,,,,,17.51,,,percent of total billed charges,,,,,,,,,,,,,,,21.52,,,percent of total billed charges,,,,,,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,36.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,31.01,,,percent of total billed charges,,,,,,27.36,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SPIRAL ELECTRODE,27290812,CDM,0272,RC,,,,,,inpatient,facility,,,38.57,38.57,17.36,38.57,,,,,,,,,,,,,,,,,,,,32.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,27,,,percent of total billed charges,,,,,,23.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,32.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,38.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,17.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.78,,,percent of total billed charges,,,,,,,,,,,,,,
HC SPIRAL ELECTRODE,27290812,CDM,0272,RC,,,,,,outpatient,facility,,,38.57,38.57,7.33,1016,,25.07,,,percent of total billed charges,,,,,,,,,,,,,,,32.78,,,percent of total billed charges,,,,,,11.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,18.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,7.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,7.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,28.92,,,percent of total billed charges,,,,,,27,,,percent of total billed charges,,,,,,27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,25.07,,,percent of total billed charges,,,,,,9.26,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",26.03,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,38.57,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,16.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",27,,,percent of total billed charges,,,,,,,,,,,,,,,38.57,,,percent of total billed charges,,,,,,26.9,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,27.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,27,,,percent of total billed charges,,,,,,23.14,,,percent of total billed charges,,,,,,17.36,,,percent of total billed charges,,,,,,,,,,,,,,,32.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.57,,,percent of total billed charges,,,,,,38.57,,,percent of total billed charges,,,,,,16.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,38.57,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,38.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.93,,,percent of total billed charges,,,,,,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,38.57,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,38.57,,,percent of total billed charges,,,,,,17.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.57,,,fee schedule,,,,,,38.57,,,percent of total billed charges,,,,,,38.57,,,percent of total billed charges,,,,,,38.57,,,percent of total billed charges,,,,,,18.51,,,percent of total billed charges,,,,,,,,,,,,,,,22.76,,,percent of total billed charges,,,,,,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,38.57,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,32.78,,,percent of total billed charges,,,,,,28.93,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC UTERINE CATHETER,27290813,CDM,0272,RC,,,,,,inpatient,facility,,,92.39,92.39,41.58,92.39,,,,,,,,,,,,,,,,,,,,78.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,64.67,,,percent of total billed charges,,,,,,55.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,78.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,92.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,41.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.53,,,percent of total billed charges,,,,,,,,,,,,,,
HC UTERINE CATHETER,27290813,CDM,0272,RC,,,,,,outpatient,facility,,,92.39,92.39,17.55,1016,,60.05,,,percent of total billed charges,,,,,,,,,,,,,,,78.53,,,percent of total billed charges,,,,,,27.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,43.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,17.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,69.29,,,percent of total billed charges,,,,,,64.67,,,percent of total billed charges,,,,,,64.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,60.05,,,percent of total billed charges,,,,,,22.17,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",62.36,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,92.39,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,38.8,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",64.67,,,percent of total billed charges,,,,,,,,,,,,,,,92.39,,,percent of total billed charges,,,,,,64.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,65.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,64.67,,,percent of total billed charges,,,,,,55.43,,,percent of total billed charges,,,,,,41.58,,,percent of total billed charges,,,,,,,,,,,,,,,78.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,percent of total billed charges,,,,,,92.39,,,percent of total billed charges,,,,,,39.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,92.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.29,,,percent of total billed charges,,,,,,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.39,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,92.39,,,percent of total billed charges,,,,,,41.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.39,,,fee schedule,,,,,,92.39,,,percent of total billed charges,,,,,,92.39,,,percent of total billed charges,,,,,,92.39,,,percent of total billed charges,,,,,,44.35,,,percent of total billed charges,,,,,,,,,,,,,,,54.51,,,percent of total billed charges,,,,,,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,92.39,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,78.53,,,percent of total billed charges,,,,,,69.29,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC VACUUM EXTRACTOR,27290830,CDM,0272,RC,,,,,,inpatient,facility,,,115.42,115.42,51.94,115.42,,,,,,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,80.79,,,percent of total billed charges,,,,,,69.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,51.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,,,,,,,,,
HC VACUUM EXTRACTOR,27290830,CDM,0272,RC,,,,,,outpatient,facility,,,115.42,115.42,21.93,1016,,75.02,,,percent of total billed charges,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,34.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,21.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,86.57,,,percent of total billed charges,,,,,,80.79,,,percent of total billed charges,,,,,,80.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,75.02,,,percent of total billed charges,,,,,,27.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.91,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,115.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.48,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",80.79,,,percent of total billed charges,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,80.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,81.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,80.79,,,percent of total billed charges,,,,,,69.25,,,percent of total billed charges,,,,,,51.94,,,percent of total billed charges,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,49.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,percent of total billed charges,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,115.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,115.42,,,percent of total billed charges,,,,,,51.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,fee schedule,,,,,,115.42,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,55.4,,,percent of total billed charges,,,,,,,,,,,,,,,68.1,,,percent of total billed charges,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,98.11,,,percent of total billed charges,,,,,,86.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC PROSTATE COILS,27290902,CDM,0272,RC,C1770,HCPCS,,,,inpatient,facility,,,447.2,447.2,201.24,447.2,,,,,,,,,,,,,,,,,,,,380.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,335.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,313.04,,,percent of total billed charges,,,,,,268.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,380.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,335.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,447.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,201.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,380.12,,,percent of total billed charges,,,,,,,,,,,,,,
HC PROSTATE COILS,27290902,CDM,0272,RC,C1770,HCPCS,,,,outpatient,facility,,,447.2,447.2,84.97,1016,,290.68,,,percent of total billed charges,,,,,,,,,,,,,,,380.12,,,percent of total billed charges,,,,,,134.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,210.18,,,percent of total billed charges,,,,,,301.86,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,84.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,84.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,335.4,,,percent of total billed charges,,,,,,313.04,,,percent of total billed charges,,,,,,313.04,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,290.68,,,percent of total billed charges,,,,,,107.33,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",301.86,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,447.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,187.82,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",313.04,,,percent of total billed charges,,,,,,,,,,,,,,,447.2,,,percent of total billed charges,,,,,,311.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,317.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,313.04,,,percent of total billed charges,,,,,,268.32,,,percent of total billed charges,,,,,,201.24,,,percent of total billed charges,,,,,,,,,,,,,,,380.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.2,,,percent of total billed charges,,,,,,447.2,,,percent of total billed charges,,,,,,192.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,447.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,447.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,335.4,,,percent of total billed charges,,,,,,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,447.2,,,percent of total billed charges,,,,,,201.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,335.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,447.2,,,fee schedule,,,,,,447.2,,,percent of total billed charges,,,,,,447.2,,,percent of total billed charges,,,,,,447.2,,,percent of total billed charges,,,,,,214.66,,,percent of total billed charges,,,,,,,,,,,,,,,263.85,,,percent of total billed charges,,,,,,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,447.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,380.12,,,percent of total billed charges,,,,,,335.4,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC ZZ TRAY MYELOGRAM,27292010,CDM,0272,RC,,,,,,inpatient,facility,,,25.9,25.9,11.65,25.9,,,,,,,,,,,,,,,,,,,,22.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,18.13,,,percent of total billed charges,,,,,,15.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,22.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,25.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,11.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.01,,,percent of total billed charges,,,,,,,,,,,,,,
HC ZZ TRAY MYELOGRAM,27292010,CDM,0272,RC,,,,,,outpatient,facility,,,25.9,25.9,4.92,1016,,16.84,,,percent of total billed charges,,,,,,,,,,,,,,,22.01,,,percent of total billed charges,,,,,,7.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,4.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,4.92,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,19.42,,,percent of total billed charges,,,,,,18.13,,,percent of total billed charges,,,,,,18.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,16.84,,,percent of total billed charges,,,,,,6.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",17.48,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,25.9,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,10.88,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",18.13,,,percent of total billed charges,,,,,,,,,,,,,,,25.9,,,percent of total billed charges,,,,,,18.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,18.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,18.13,,,percent of total billed charges,,,,,,15.54,,,percent of total billed charges,,,,,,11.65,,,percent of total billed charges,,,,,,,,,,,,,,,22.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.9,,,percent of total billed charges,,,,,,25.9,,,percent of total billed charges,,,,,,11.14,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,25.9,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,25.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.42,,,percent of total billed charges,,,,,,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,25.9,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,25.9,,,percent of total billed charges,,,,,,11.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.9,,,fee schedule,,,,,,25.9,,,percent of total billed charges,,,,,,25.9,,,percent of total billed charges,,,,,,25.9,,,percent of total billed charges,,,,,,12.43,,,percent of total billed charges,,,,,,,,,,,,,,,15.28,,,percent of total billed charges,,,,,,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,25.9,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.01,,,percent of total billed charges,,,,,,19.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC PASSY MUIR VALVE,27292583,CDM,0272,RC,,,,,,inpatient,facility,,,373.76,373.76,168.19,373.76,,,,,,,,,,,,,,,,,,,,317.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,242.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,261.63,,,percent of total billed charges,,,,,,224.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,317.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,373.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,168.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.7,,,percent of total billed charges,,,,,,,,,,,,,,
HC PASSY MUIR VALVE,27292583,CDM,0272,RC,,,,,,outpatient,facility,,,373.76,373.76,71.01,1016,,242.94,,,percent of total billed charges,,,,,,,,,,,,,,,317.7,,,percent of total billed charges,,,,,,112.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,175.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,71.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,71.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,280.32,,,percent of total billed charges,,,,,,261.63,,,percent of total billed charges,,,,,,261.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,242.94,,,percent of total billed charges,,,,,,89.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252.29,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,373.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,156.98,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",261.63,,,percent of total billed charges,,,,,,,,,,,,,,,373.76,,,percent of total billed charges,,,,,,260.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,265.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,261.63,,,percent of total billed charges,,,,,,224.26,,,percent of total billed charges,,,,,,168.19,,,percent of total billed charges,,,,,,,,,,,,,,,317.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.76,,,percent of total billed charges,,,,,,373.76,,,percent of total billed charges,,,,,,160.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,373.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,373.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.32,,,percent of total billed charges,,,,,,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,373.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,373.76,,,percent of total billed charges,,,,,,168.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,280.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,373.76,,,fee schedule,,,,,,373.76,,,percent of total billed charges,,,,,,373.76,,,percent of total billed charges,,,,,,373.76,,,percent of total billed charges,,,,,,179.4,,,percent of total billed charges,,,,,,,,,,,,,,,220.52,,,percent of total billed charges,,,,,,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,373.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,317.7,,,percent of total billed charges,,,,,,280.32,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC OXYGEN HOOD  PEDS,27292626,CDM,0272,RC,,,,,,inpatient,facility,,,155.78,155.78,70.1,155.78,,,,,,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,109.05,,,percent of total billed charges,,,,,,93.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,,,,,,,,,
HC OXYGEN HOOD  PEDS,27292626,CDM,0272,RC,,,,,,outpatient,facility,,,155.78,155.78,29.6,1016,,101.26,,,percent of total billed charges,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,46.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,29.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,116.83,,,percent of total billed charges,,,,,,109.05,,,percent of total billed charges,,,,,,109.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.26,,,percent of total billed charges,,,,,,37.39,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",105.15,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.78,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.43,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",109.05,,,percent of total billed charges,,,,,,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,108.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,109.05,,,percent of total billed charges,,,,,,93.47,,,percent of total billed charges,,,,,,70.1,,,percent of total billed charges,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,155.78,,,percent of total billed charges,,,,,,66.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.78,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.78,,,percent of total billed charges,,,,,,70.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,,fee schedule,,,,,,155.78,,,percent of total billed charges,,,,,,155.78,,,percent of total billed charges,,,,,,155.78,,,percent of total billed charges,,,,,,74.77,,,percent of total billed charges,,,,,,,,,,,,,,,91.91,,,percent of total billed charges,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.41,,,percent of total billed charges,,,,,,116.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC NEEDLE PROSTATE BEST,27294130,CDM,0272,RC,C1715,HCPCS,,,,inpatient,facility,,,61.3,61.3,27.59,61.3,,,,,,,,,,,,,,,,,,,,52.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,42.91,,,percent of total billed charges,,,,,,36.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,52.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,61.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.1,,,percent of total billed charges,,,,,,,,,,,,,,
HC NEEDLE PROSTATE BEST,27294130,CDM,0272,RC,C1715,HCPCS,,,,outpatient,facility,,,61.3,61.3,11.65,1016,,39.84,,,percent of total billed charges,,,,,,,,,,,,,,,52.1,,,percent of total billed charges,,,,,,18.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,28.81,,,percent of total billed charges,,,,,,41.37,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,11.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,11.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,45.98,,,percent of total billed charges,,,,,,42.91,,,percent of total billed charges,,,,,,42.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,39.84,,,percent of total billed charges,,,,,,14.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",41.38,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,61.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,25.75,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",42.91,,,percent of total billed charges,,,,,,,,,,,,,,,61.3,,,percent of total billed charges,,,,,,42.76,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,43.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,42.91,,,percent of total billed charges,,,,,,36.78,,,percent of total billed charges,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,52.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.3,,,percent of total billed charges,,,,,,61.3,,,percent of total billed charges,,,,,,26.36,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,61.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,61.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,61.3,,,percent of total billed charges,,,,,,27.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.3,,,fee schedule,,,,,,61.3,,,percent of total billed charges,,,,,,61.3,,,percent of total billed charges,,,,,,61.3,,,percent of total billed charges,,,,,,29.42,,,percent of total billed charges,,,,,,,,,,,,,,,36.17,,,percent of total billed charges,,,,,,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,61.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,52.1,,,percent of total billed charges,,,,,,45.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC PROXIMA BALLOON CATHETER,27294131,CDM,0272,RC,C1728,HCPCS,,,,inpatient,facility,,,13371.88,13371.88,6017.35,13371.88,,,,,,,,,,,,,,,,,,,,11366.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8691.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9494.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,9360.32,,,percent of total billed charges,,,,,,8023.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,11366.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13371.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13371.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6017.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11366.1,,,percent of total billed charges,,,,,,,,,,,,,,
HC PROXIMA BALLOON CATHETER,27294131,CDM,0272,RC,C1728,HCPCS,,,,outpatient,facility,,,13371.88,13371.88,129.72,13371.88,,8691.72,,,percent of total billed charges,,,,,,,,,,,,,,,11366.1,,,percent of total billed charges,,,,,,4011.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,6284.78,,,percent of total billed charges,,,,,,9026.02,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,2540.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2540.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,10028.91,,,percent of total billed charges,,,,,,9360.32,,,percent of total billed charges,,,,,,9360.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,8691.72,,,percent of total billed charges,,,,,,2000,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",9026.02,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13371.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2657,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",9360.32,,,percent of total billed charges,,,,,,,,,,,,,,,13371.88,,,percent of total billed charges,,,,,,9326.89,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,9494.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,9360.32,,,percent of total billed charges,,,,,,8023.13,,,percent of total billed charges,,,,,,6017.35,,,percent of total billed charges,,,,,,,,,,,,,,,11366.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13371.88,,,percent of total billed charges,,,,,,13371.88,,,percent of total billed charges,,,,,,3254,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,13371.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,13371.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.91,,,percent of total billed charges,,,,,,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,13371.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,13371.88,,,percent of total billed charges,,,,,,6017.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10028.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13371.88,,,fee schedule,,,,,,13371.88,,,percent of total billed charges,,,,,,13371.88,,,percent of total billed charges,,,,,,13371.88,,,percent of total billed charges,,,,,,6418.5,,,percent of total billed charges,,,,,,,,,,,,,,,7889.41,,,percent of total billed charges,,,,,,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,13371.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,11366.1,,,percent of total billed charges,,,,,,10028.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC CATH BRACHYTHERAPY SEED ADMIN,27294132,CDM,0272,RC,C1728,HCPCS,,,,inpatient,facility,,,115.42,115.42,51.94,115.42,,,,,,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,80.79,,,percent of total billed charges,,,,,,69.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,51.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,,,,,,,,,
HC CATH BRACHYTHERAPY SEED ADMIN,27294132,CDM,0272,RC,C1728,HCPCS,,,,outpatient,facility,,,115.42,115.42,21.93,1016,,75.02,,,percent of total billed charges,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,34.63,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,54.25,,,percent of total billed charges,,,,,,77.91,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,21.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,86.57,,,percent of total billed charges,,,,,,80.79,,,percent of total billed charges,,,,,,80.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,75.02,,,percent of total billed charges,,,,,,27.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",77.91,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,115.42,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,48.48,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",80.79,,,percent of total billed charges,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,80.51,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,81.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,80.79,,,percent of total billed charges,,,,,,69.25,,,percent of total billed charges,,,,,,51.94,,,percent of total billed charges,,,,,,,,,,,,,,,98.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,49.63,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,percent of total billed charges,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,115.42,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,115.42,,,percent of total billed charges,,,,,,51.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.42,,,fee schedule,,,,,,115.42,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,55.4,,,percent of total billed charges,,,,,,,,,,,,,,,68.1,,,percent of total billed charges,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,115.42,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,98.11,,,percent of total billed charges,,,,,,86.56,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC PRISMASATE SOLUTION 5 LITER BAG,27295111,CDM,0272,RC,,,,,,inpatient,facility,,,104,104,46.8,104,,,,,,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,62.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,104,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,
HC PRISMASATE SOLUTION 5 LITER BAG,27295111,CDM,0272,RC,,,,,,outpatient,facility,,,104,104,19.76,1016,,67.6,,,percent of total billed charges,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,31.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,19.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,19.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,78,,,percent of total billed charges,,,,,,72.8,,,percent of total billed charges,,,,,,72.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,67.6,,,percent of total billed charges,,,,,,24.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",70.2,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,104,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,43.68,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",72.8,,,percent of total billed charges,,,,,,,,,,,,,,,104,,,percent of total billed charges,,,,,,72.54,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,73.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,62.4,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,,percent of total billed charges,,,,,,104,,,percent of total billed charges,,,,,,44.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,104,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,104,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,,fee schedule,,,,,,104,,,percent of total billed charges,,,,,,104,,,percent of total billed charges,,,,,,104,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,61.36,,,percent of total billed charges,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,88.4,,,percent of total billed charges,,,,,,78,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC CRRT CARTRIDGE CHANGE,27295197,CDM,0272,RC,,,,,,inpatient,facility,,,616.24,616.24,277.31,616.24,,,,,,,,,,,,,,,,,,,,523.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,431.37,,,percent of total billed charges,,,,,,369.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,523.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,616.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,277.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,523.8,,,percent of total billed charges,,,,,,,,,,,,,,
HC CRRT CARTRIDGE CHANGE,27295197,CDM,0272,RC,,,,,,outpatient,facility,,,616.24,616.24,117.09,1016,,400.56,,,percent of total billed charges,,,,,,,,,,,,,,,523.8,,,percent of total billed charges,,,,,,184.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,289.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,117.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,117.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,462.18,,,percent of total billed charges,,,,,,431.37,,,percent of total billed charges,,,,,,431.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,400.56,,,percent of total billed charges,,,,,,147.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",415.96,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,616.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,258.82,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",431.37,,,percent of total billed charges,,,,,,,,,,,,,,,616.24,,,percent of total billed charges,,,,,,429.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,437.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,431.37,,,percent of total billed charges,,,,,,369.74,,,percent of total billed charges,,,,,,277.31,,,percent of total billed charges,,,,,,,,,,,,,,,523.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.24,,,percent of total billed charges,,,,,,616.24,,,percent of total billed charges,,,,,,264.98,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,616.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,616.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.18,,,percent of total billed charges,,,,,,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,616.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,616.24,,,percent of total billed charges,,,,,,277.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.24,,,fee schedule,,,,,,616.24,,,percent of total billed charges,,,,,,616.24,,,percent of total billed charges,,,,,,616.24,,,percent of total billed charges,,,,,,295.8,,,percent of total billed charges,,,,,,,,,,,,,,,363.58,,,percent of total billed charges,,,,,,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,616.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,523.8,,,percent of total billed charges,,,,,,462.18,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC CCPD ADDITIONAL LITERS   12,27295244,CDM,0272,RC,,,,,,inpatient,facility,,,104,104,46.8,104,,,,,,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,62.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,104,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,
HC CCPD ADDITIONAL LITERS   12,27295244,CDM,0272,RC,,,,,,outpatient,facility,,,104,104,19.76,1016,,67.6,,,percent of total billed charges,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,31.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,19.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,19.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,78,,,percent of total billed charges,,,,,,72.8,,,percent of total billed charges,,,,,,72.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,67.6,,,percent of total billed charges,,,,,,24.96,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",70.2,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,104,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,43.68,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",72.8,,,percent of total billed charges,,,,,,,,,,,,,,,104,,,percent of total billed charges,,,,,,72.54,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,73.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,,62.4,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,,percent of total billed charges,,,,,,104,,,percent of total billed charges,,,,,,44.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,104,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,104,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,104,,,percent of total billed charges,,,,,,46.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104,,,fee schedule,,,,,,104,,,percent of total billed charges,,,,,,104,,,percent of total billed charges,,,,,,104,,,percent of total billed charges,,,,,,49.92,,,percent of total billed charges,,,,,,,,,,,,,,,61.36,,,percent of total billed charges,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,104,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,88.4,,,percent of total billed charges,,,,,,78,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC EXTRA DIALYZER,27295669,CDM,0272,RC,,,,,,inpatient,facility,,,65,65,29.25,65,,,,,,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,45.5,,,percent of total billed charges,,,,,,39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,
HC EXTRA DIALYZER,27295669,CDM,0272,RC,,,,,,outpatient,facility,,,65,65,12.35,1016,,42.25,,,percent of total billed charges,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,19.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,30.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,12.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,48.76,,,percent of total billed charges,,,,,,45.5,,,percent of total billed charges,,,,,,45.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,42.25,,,percent of total billed charges,,,,,,15.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",43.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,27.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",45.5,,,percent of total billed charges,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,,,,45.34,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,46.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,45.5,,,percent of total billed charges,,,,,,39,,,percent of total billed charges,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,,,,65,,,percent of total billed charges,,,,,,27.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.75,,,percent of total billed charges,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,65,,,percent of total billed charges,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,fee schedule,,,,,,65,,,percent of total billed charges,,,,,,65,,,percent of total billed charges,,,,,,65,,,percent of total billed charges,,,,,,31.2,,,percent of total billed charges,,,,,,,,,,,,,,,38.35,,,percent of total billed charges,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.25,,,percent of total billed charges,,,,,,48.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC DIALYSATE ADDTL 5 LTR BAG,27295777,CDM,0272,RC,,,,,,inpatient,facility,,,65,65,29.25,65,,,,,,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,45.5,,,percent of total billed charges,,,,,,39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,
HC DIALYSATE ADDTL 5 LTR BAG,27295777,CDM,0272,RC,,,,,,outpatient,facility,,,65,65,12.35,1016,,42.25,,,percent of total billed charges,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,19.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,30.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,12.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,12.35,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,48.76,,,percent of total billed charges,,,,,,45.5,,,percent of total billed charges,,,,,,45.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,42.25,,,percent of total billed charges,,,,,,15.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",43.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,65,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,27.3,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",45.5,,,percent of total billed charges,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,,,,45.34,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,46.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,45.5,,,percent of total billed charges,,,,,,39,,,percent of total billed charges,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,,,,65,,,percent of total billed charges,,,,,,27.95,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.75,,,percent of total billed charges,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,65,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,65,,,percent of total billed charges,,,,,,29.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65,,,fee schedule,,,,,,65,,,percent of total billed charges,,,,,,65,,,percent of total billed charges,,,,,,65,,,percent of total billed charges,,,,,,31.2,,,percent of total billed charges,,,,,,,,,,,,,,,38.35,,,percent of total billed charges,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,65,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.25,,,percent of total billed charges,,,,,,48.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BIOPSY NEEDLE,27296660,CDM,0272,RC,,,,,,inpatient,facility,,,235.31,235.31,105.89,235.31,,,,,,,,,,,,,,,,,,,,200.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.72,,,percent of total billed charges,,,,,,141.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,200.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,235.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,105.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.01,,,percent of total billed charges,,,,,,,,,,,,,,
HC BIOPSY NEEDLE,27296660,CDM,0272,RC,,,,,,outpatient,facility,,,235.31,235.31,44.71,1016,,152.95,,,percent of total billed charges,,,,,,,,,,,,,,,200.01,,,percent of total billed charges,,,,,,70.59,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,110.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,44.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,44.71,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,176.48,,,percent of total billed charges,,,,,,164.72,,,percent of total billed charges,,,,,,164.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,152.95,,,percent of total billed charges,,,,,,56.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",158.83,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,235.31,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,98.83,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",164.72,,,percent of total billed charges,,,,,,,,,,,,,,,235.31,,,percent of total billed charges,,,,,,164.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,167.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,164.72,,,percent of total billed charges,,,,,,141.19,,,percent of total billed charges,,,,,,105.89,,,percent of total billed charges,,,,,,,,,,,,,,,200.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.31,,,percent of total billed charges,,,,,,235.31,,,percent of total billed charges,,,,,,101.18,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,235.31,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,235.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.48,,,percent of total billed charges,,,,,,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,235.31,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,235.31,,,percent of total billed charges,,,,,,105.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,235.31,,,fee schedule,,,,,,235.31,,,percent of total billed charges,,,,,,235.31,,,percent of total billed charges,,,,,,235.31,,,percent of total billed charges,,,,,,112.95,,,percent of total billed charges,,,,,,,,,,,,,,,138.83,,,percent of total billed charges,,,,,,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,235.31,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,200.01,,,percent of total billed charges,,,,,,176.48,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BIOPSY FORCEP DISPOS,27296664,CDM,0272,RC,,,,,,inpatient,facility,,,173.72,173.72,78.17,173.72,,,,,,,,,,,,,,,,,,,,147.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,121.6,,,percent of total billed charges,,,,,,104.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,147.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,173.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,78.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.66,,,percent of total billed charges,,,,,,,,,,,,,,
HC BIOPSY FORCEP DISPOS,27296664,CDM,0272,RC,,,,,,outpatient,facility,,,173.72,173.72,33.01,1016,,112.92,,,percent of total billed charges,,,,,,,,,,,,,,,147.66,,,percent of total billed charges,,,,,,52.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,81.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,33.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,130.29,,,percent of total billed charges,,,,,,121.6,,,percent of total billed charges,,,,,,121.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,112.92,,,percent of total billed charges,,,,,,41.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",117.26,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,173.72,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,72.96,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",121.6,,,percent of total billed charges,,,,,,,,,,,,,,,173.72,,,percent of total billed charges,,,,,,121.17,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,123.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,121.6,,,percent of total billed charges,,,,,,104.23,,,percent of total billed charges,,,,,,78.17,,,percent of total billed charges,,,,,,,,,,,,,,,147.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.72,,,percent of total billed charges,,,,,,173.72,,,percent of total billed charges,,,,,,74.7,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,173.72,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,173.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.29,,,percent of total billed charges,,,,,,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,173.72,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,173.72,,,percent of total billed charges,,,,,,78.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,173.72,,,fee schedule,,,,,,173.72,,,percent of total billed charges,,,,,,173.72,,,percent of total billed charges,,,,,,173.72,,,percent of total billed charges,,,,,,83.39,,,percent of total billed charges,,,,,,,,,,,,,,,102.49,,,percent of total billed charges,,,,,,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,173.72,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,147.66,,,percent of total billed charges,,,,,,130.29,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC TRAY BONE MARROW,27298028,CDM,0272,RC,,,,,,inpatient,facility,,,275.38,275.38,123.92,275.38,,,,,,,,,,,,,,,,,,,,234.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,192.77,,,percent of total billed charges,,,,,,165.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,234.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,275.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,123.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,234.07,,,percent of total billed charges,,,,,,,,,,,,,,
HC TRAY BONE MARROW,27298028,CDM,0272,RC,,,,,,outpatient,facility,,,275.38,275.38,52.32,1016,,179,,,percent of total billed charges,,,,,,,,,,,,,,,234.07,,,percent of total billed charges,,,,,,82.61,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,129.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,52.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,52.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,206.53,,,percent of total billed charges,,,,,,192.77,,,percent of total billed charges,,,,,,192.77,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,179,,,percent of total billed charges,,,,,,66.09,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",185.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,275.38,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,115.66,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",192.77,,,percent of total billed charges,,,,,,,,,,,,,,,275.38,,,percent of total billed charges,,,,,,192.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,195.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,192.77,,,percent of total billed charges,,,,,,165.23,,,percent of total billed charges,,,,,,123.92,,,percent of total billed charges,,,,,,,,,,,,,,,234.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.38,,,percent of total billed charges,,,,,,275.38,,,percent of total billed charges,,,,,,118.41,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,275.38,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,275.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.54,,,percent of total billed charges,,,,,,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,275.38,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,275.38,,,percent of total billed charges,,,,,,123.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,275.38,,,fee schedule,,,,,,275.38,,,percent of total billed charges,,,,,,275.38,,,percent of total billed charges,,,,,,275.38,,,percent of total billed charges,,,,,,132.18,,,percent of total billed charges,,,,,,,,,,,,,,,162.47,,,percent of total billed charges,,,,,,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,275.38,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,234.07,,,percent of total billed charges,,,,,,206.53,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BLOOD FILTER RC 50,27298046,CDM,0272,RC,,,,,,inpatient,facility,,,155.78,155.78,70.1,155.78,,,,,,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,109.05,,,percent of total billed charges,,,,,,93.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,,,,,,,,,
HC BLOOD FILTER RC 50,27298046,CDM,0272,RC,,,,,,outpatient,facility,,,155.78,155.78,29.6,1016,,101.26,,,percent of total billed charges,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,46.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,29.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,116.83,,,percent of total billed charges,,,,,,109.05,,,percent of total billed charges,,,,,,109.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,101.26,,,percent of total billed charges,,,,,,37.39,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,37.39,37.39,37.39,1 through 10,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",105.15,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.78,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.43,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,66.95,66.95,66.95,1 through 10,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",109.05,,,percent of total billed charges,,,,,,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,108.66,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,109.05,,,percent of total billed charges,,,,,,93.47,,,percent of total billed charges,,,,,,70.1,,,percent of total billed charges,,,,,,,,,,,,,,,132.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,155.78,,,percent of total billed charges,,,,,,66.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,37.39,37.39,37.39,1 through 10,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,,,,,,,,,service not payable,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.78,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.78,,,percent of total billed charges,,,,,,70.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.78,,,fee schedule,,,,,,155.78,,,percent of total billed charges,,,,,,155.78,,,percent of total billed charges,,,,,,155.78,,,percent of total billed charges,,,,,,74.77,,,percent of total billed charges,,,,,,,,,,,,,,,91.91,,,percent of total billed charges,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.78,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,132.41,,,percent of total billed charges,,,,,,116.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC MAMMOTONE 15P NDL,27298082,CDM,0272,RC,,,,,,inpatient,facility,,,727.17,727.17,327.23,727.17,,,,,,,,,,,,,,,,,,,,618.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,472.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,509.02,,,percent of total billed charges,,,,,,436.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,618.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,727.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,327.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,618.09,,,percent of total billed charges,,,,,,,,,,,,,,
HC MAMMOTONE 15P NDL,27298082,CDM,0272,RC,,,,,,outpatient,facility,,,727.17,727.17,129.72,1016,,472.66,,,percent of total billed charges,,,,,,,,,,,,,,,618.09,,,percent of total billed charges,,,,,,218.15,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,341.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,138.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,138.16,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,545.38,,,percent of total billed charges,,,,,,509.02,,,percent of total billed charges,,,,,,509.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,472.66,,,percent of total billed charges,,,,,,174.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,174.52,174.52,174.52,1 through 10,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",490.84,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,727.17,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,305.41,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,237.13,167.44,237.13,1 through 10,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",509.02,,,percent of total billed charges,,,,,,,,,,,,,,,727.17,,,percent of total billed charges,,,,,,507.2,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,516.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,509.02,,,percent of total billed charges,,,,,,436.3,,,percent of total billed charges,,,,,,327.23,,,percent of total billed charges,,,,,,,,,,,,,,,618.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.17,,,percent of total billed charges,,,,,,727.17,,,percent of total billed charges,,,,,,312.68,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,727.17,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,727.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.38,,,percent of total billed charges,,,,,,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,727.17,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,727.17,,,percent of total billed charges,,,,,,327.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,727.17,,,fee schedule,,,,,,727.17,,,percent of total billed charges,,,,,,727.17,,,percent of total billed charges,,,,,,727.17,,,percent of total billed charges,,,,,,349.04,,,percent of total billed charges,,,,,,,,,,,,,,,429.03,,,percent of total billed charges,,,,,,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,727.17,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,618.09,,,percent of total billed charges,,,,,,545.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 32 X 105,27594,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 32 X 105,27594,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 32 X 120,27597,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 32 X 120,27597,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 32 X 125,27598,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 32 X 125,27598,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 32 X 130,27599,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 32 X 130,27599,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX 5percent INJ 250ML 2B0062Q  i,276,CDM,0258,RC,,,,,,inpatient,facility,,,5.22,5.22,2.35,5.22,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.65,,,percent of total billed charges,,,,,,3.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent INJ 250ML 2B0062Q  i,276,CDM,0258,RC,,,,,,outpatient,facility,,,5.22,5.22,0.99,1016,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,1.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.91,,,percent of total billed charges,,,,,,3.65,,,percent of total billed charges,,,,,,3.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,1.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,5.22,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.19,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.65,,,percent of total billed charges,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,3.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.65,,,percent of total billed charges,,,,,,3.13,,,percent of total billed charges,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,4.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,5.22,,,percent of total billed charges,,,,,,2.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.22,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.22,,,percent of total billed charges,,,,,,2.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.22,,,fee schedule,,,,,,5.22,,,percent of total billed charges,,,,,,5.22,,,percent of total billed charges,,,,,,5.22,,,percent of total billed charges,,,,,,2.51,,,percent of total billed charges,,,,,,,,,,,,,,,3.08,,,percent of total billed charges,,,,,,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.44,,,percent of total billed charges,,,,,,3.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 32 X 135,27600,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 32 X 135,27600,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 32 X 140,27601,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 32 X 140,27601,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 32 X 145,27602,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 32 X 145,27602,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 32 X 150,27603,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 32 X 150,27603,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CUP DEP HIP SECTOR DURALOC 52MM,27647,CDM,0278,RC,,,,,,inpatient,facility,,,1890,1890,850.5,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1512,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1417.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1142.51,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1890,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,1228.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
CUP DEP HIP SECTOR DURALOC 52MM,27647,CDM,0278,RC,,,,,,outpatient,facility,,,1890,1890,129.72,1890,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1606.5,,,percent of total billed charges,,,,,,567,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,359.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1417.5,,,percent of total billed charges,,,,,,1323,,,percent of total billed charges,,,,,,1323,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1228.5,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1890,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1039.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1318.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1341.9,,,percent of total billed charges,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1323,,,percent of total billed charges,,,,,,1134,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1606.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1890,,,percent of total billed charges,,,,,,850.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1417.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1890,,,fee schedule,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1890,,,percent of total billed charges,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1039.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1890,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1606.5,,,percent of total billed charges,,,,,,1417.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LINER DEP HIP POLY M 10DG X 28,27650,CDM,0278,RC,,,,,,inpatient,facility,,,1100,1100,495,1100,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,935,,,percent of total billed charges,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,880,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,825,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,605,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,664.95,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",781,,,percent of total billed charges,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,770,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,935,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1100,,,percent of total billed charges,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,825,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1100,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,495,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,935,,,percent of total billed charges,,,,,,715,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
LINER DEP HIP POLY M 10DG X 28,27650,CDM,0278,RC,,,,,,outpatient,facility,,,1100,1100,129.72,1100,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,935,,,percent of total billed charges,,,,,,330,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,209,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,209,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,825,,,percent of total billed charges,,,,,,770,,,percent of total billed charges,,,,,,770,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,715,,,percent of total billed charges,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1100,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,770,,,percent of total billed charges,,,,,,605,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1100,,,percent of total billed charges,,,,,,767.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,781,,,percent of total billed charges,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,770,,,percent of total billed charges,,,,,,660,,,percent of total billed charges,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,935,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,605,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1100,,,percent of total billed charges,,,,,,1100,,,percent of total billed charges,,,,,,605,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1100,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1100,,,percent of total billed charges,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,825,,,percent of total billed charges,,,,,,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1100,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1100,,,percent of total billed charges,,,,,,495,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,825,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1100,,,fee schedule,,,,,,1100,,,percent of total billed charges,,,,,,1100,,,percent of total billed charges,,,,,,1100,,,percent of total billed charges,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,605,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1100,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,935,,,percent of total billed charges,,,,,,825,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANC SS FULL TH 6.5 X 25,27657,CDM,0278,RC,,,,,,inpatient,facility,,,133.3,133.3,59.99,133.3,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,99.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.58,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.31,,,percent of total billed charges,,,,,,79.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,86.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANC SS FULL TH 6.5 X 25,27657,CDM,0278,RC,,,,,,outpatient,facility,,,133.3,133.3,25.33,138.8,,86.64,,,percent of total billed charges,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,39.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,25.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.98,,,percent of total billed charges,,,,,,93.31,,,percent of total billed charges,,,,,,93.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.65,,,percent of total billed charges,,,,,,31.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,133.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.31,,,percent of total billed charges,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,92.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.31,,,percent of total billed charges,,,,,,79.98,,,percent of total billed charges,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,57.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,,percent of total billed charges,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,fee schedule,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.3,,,percent of total billed charges,,,,,,99.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANC SS FULL TH 6.5 X 30,27658,CDM,0278,RC,,,,,,inpatient,facility,,,133.3,133.3,59.99,133.3,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,99.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.58,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.31,,,percent of total billed charges,,,,,,79.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,86.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANC SS FULL TH 6.5 X 30,27658,CDM,0278,RC,,,,,,outpatient,facility,,,133.3,133.3,25.33,138.8,,86.64,,,percent of total billed charges,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,39.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,25.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.98,,,percent of total billed charges,,,,,,93.31,,,percent of total billed charges,,,,,,93.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.65,,,percent of total billed charges,,,,,,31.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,133.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.31,,,percent of total billed charges,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,92.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.31,,,percent of total billed charges,,,,,,79.98,,,percent of total billed charges,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,57.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,,percent of total billed charges,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,fee schedule,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.3,,,percent of total billed charges,,,,,,99.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANC SS FULL TH 6.5 X 35,27659,CDM,0278,RC,,,,,,inpatient,facility,,,133.3,133.3,59.99,133.3,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,99.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.58,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.31,,,percent of total billed charges,,,,,,79.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,86.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANC SS FULL TH 6.5 X 35,27659,CDM,0278,RC,,,,,,outpatient,facility,,,133.3,133.3,25.33,138.8,,86.64,,,percent of total billed charges,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,39.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,25.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.98,,,percent of total billed charges,,,,,,93.31,,,percent of total billed charges,,,,,,93.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.65,,,percent of total billed charges,,,,,,31.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,133.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.31,,,percent of total billed charges,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,92.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.31,,,percent of total billed charges,,,,,,79.98,,,percent of total billed charges,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,57.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,,percent of total billed charges,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,fee schedule,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.3,,,percent of total billed charges,,,,,,99.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANC SS FULL TH 6.5 X 40,27660,CDM,0278,RC,,,,,,inpatient,facility,,,133.3,133.3,59.99,133.3,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,99.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.58,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.31,,,percent of total billed charges,,,,,,79.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,86.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANC SS FULL TH 6.5 X 40,27660,CDM,0278,RC,,,,,,outpatient,facility,,,133.3,133.3,25.33,138.8,,86.64,,,percent of total billed charges,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,39.99,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,62.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,25.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,25.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,73.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,99.98,,,percent of total billed charges,,,,,,93.31,,,percent of total billed charges,,,,,,93.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,86.65,,,percent of total billed charges,,,,,,31.99,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,133.3,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,55.99,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",93.31,,,percent of total billed charges,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,92.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,93.31,,,percent of total billed charges,,,,,,79.98,,,percent of total billed charges,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,113.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,57.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,133.3,,,percent of total billed charges,,,,,,59.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,,fee schedule,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,133.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,133.3,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,113.3,,,percent of total billed charges,,,,,,99.97,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP DHS SS 135DG 10H 38 X 174,27689,CDM,0278,RC,,,,,,inpatient,facility,,,1705,1705,767.25,1705,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1449.25,,,percent of total billed charges,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1364,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1278.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,937.75,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1030.67,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1210.55,,,percent of total billed charges,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1193.5,,,percent of total billed charges,,,,,,1023,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1449.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1705,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1278.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1705,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,767.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.25,,,percent of total billed charges,,,,,,1108.25,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP DHS SS 135DG 10H 38 X 174,27689,CDM,0278,RC,,,,,,outpatient,facility,,,1705,1705,129.72,1705,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1449.25,,,percent of total billed charges,,,,,,511.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,323.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,323.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.76,,,percent of total billed charges,,,,,,1193.5,,,percent of total billed charges,,,,,,1193.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1108.25,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1705,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1193.5,,,percent of total billed charges,,,,,,937.75,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,,percent of total billed charges,,,,,,1189.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1210.55,,,percent of total billed charges,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1193.5,,,percent of total billed charges,,,,,,1023,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1449.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,,percent of total billed charges,,,,,,1705,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1705,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1278.75,,,percent of total billed charges,,,,,,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1705,,,percent of total billed charges,,,,,,767.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1278.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1705,,,fee schedule,,,,,,1705,,,percent of total billed charges,,,,,,1705,,,percent of total billed charges,,,,,,1705,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1449.25,,,percent of total billed charges,,,,,,1278.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP DHS SS 135DG 8H 38 X 142,27690,CDM,0278,RC,,,,,,inpatient,facility,,,1705,1705,767.25,1705,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1449.25,,,percent of total billed charges,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1364,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1278.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,937.75,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1030.67,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1210.55,,,percent of total billed charges,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1193.5,,,percent of total billed charges,,,,,,1023,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1449.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1705,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1278.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1705,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,767.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1449.25,,,percent of total billed charges,,,,,,1108.25,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP DHS SS 135DG 8H 38 X 142,27690,CDM,0278,RC,,,,,,outpatient,facility,,,1705,1705,129.72,1705,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1449.25,,,percent of total billed charges,,,,,,511.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,323.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,323.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1278.76,,,percent of total billed charges,,,,,,1193.5,,,percent of total billed charges,,,,,,1193.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1108.25,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1705,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1193.5,,,percent of total billed charges,,,,,,937.75,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,,percent of total billed charges,,,,,,1189.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1210.55,,,percent of total billed charges,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1193.5,,,percent of total billed charges,,,,,,1023,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1449.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,937.75,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,,percent of total billed charges,,,,,,1705,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1705,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1278.75,,,percent of total billed charges,,,,,,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1705,,,percent of total billed charges,,,,,,767.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1278.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1705,,,fee schedule,,,,,,1705,,,percent of total billed charges,,,,,,1705,,,percent of total billed charges,,,,,,1705,,,percent of total billed charges,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,937.75,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1705,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1449.25,,,percent of total billed charges,,,,,,1278.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH DX INFINITI PIG 5SH 4FR 110CM  ORDER SETS OF,27694,CDM,0272,RC,,,,,,inpatient,facility,,,29.26,29.26,13.17,29.26,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,
CATH DX INFINITI PIG 5SH 4FR 110CM  ORDER SETS OF,27694,CDM,0272,RC,,,,,,outpatient,facility,,,29.26,29.26,5.56,1016,,19.02,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,8.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,5.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,21.94,,,percent of total billed charges,,,,,,20.48,,,percent of total billed charges,,,,,,20.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,19.02,,,percent of total billed charges,,,,,,7.02,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",19.75,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.29,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",20.48,,,percent of total billed charges,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,20.41,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,20.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,20.48,,,percent of total billed charges,,,,,,17.56,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,24.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,12.58,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.94,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,29.26,,,percent of total billed charges,,,,,,13.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.26,,,fee schedule,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,29.26,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.26,,,percent of total billed charges,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,29.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,24.87,,,percent of total billed charges,,,,,,21.95,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX 5percent INJ 500ML 2B0063Q  i,277,CDM,0258,RC,,,,,,inpatient,facility,,,5.51,5.51,2.48,5.51,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.86,,,percent of total billed charges,,,,,,3.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent INJ 500ML 2B0063Q  i,277,CDM,0258,RC,,,,,,outpatient,facility,,,5.51,5.51,1.05,1016,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,1.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.13,,,percent of total billed charges,,,,,,3.86,,,percent of total billed charges,,,,,,3.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,1.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,5.51,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.31,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.86,,,percent of total billed charges,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,3.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.86,,,percent of total billed charges,,,,,,3.31,,,percent of total billed charges,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,4.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,5.51,,,percent of total billed charges,,,,,,2.37,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.51,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.51,,,percent of total billed charges,,,,,,2.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.51,,,fee schedule,,,,,,5.51,,,percent of total billed charges,,,,,,5.51,,,percent of total billed charges,,,,,,5.51,,,percent of total billed charges,,,,,,2.64,,,percent of total billed charges,,,,,,,,,,,,,,,3.25,,,percent of total billed charges,,,,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.51,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.68,,,percent of total billed charges,,,,,,4.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD STR XIA UNION OSS TI 250MM,27702,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD STR XIA UNION OSS TI 250MM,27702,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD STR XIA UNION OSS TI 300MM,27705,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD STR XIA UNION OSS TI 300MM,27705,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP DHS SS 95DG 8H 25 X 146,27706,CDM,0278,RC,,,,,,inpatient,facility,,,2220,2220,999,2220,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1887,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1776,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1665,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1221,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1341.99,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1576.2,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1554,,,percent of total billed charges,,,,,,1332,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1887,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,999,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1887,,,percent of total billed charges,,,,,,1443,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP DHS SS 95DG 8H 25 X 146,27706,CDM,0278,RC,,,,,,outpatient,facility,,,2220,2220,129.72,2220,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1887,,,percent of total billed charges,,,,,,666,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,421.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,421.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1665,,,percent of total billed charges,,,,,,1554,,,percent of total billed charges,,,,,,1554,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1443,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1554,,,percent of total billed charges,,,,,,1221,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,1548.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1576.2,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1554,,,percent of total billed charges,,,,,,1332,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1887,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,,percent of total billed charges,,,,,,999,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2220,,,fee schedule,,,,,,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1887,,,percent of total billed charges,,,,,,1665,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP DHS SS 95DG 10H 25 X 178,27707,CDM,0278,RC,,,,,,inpatient,facility,,,2220,2220,999,2220,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1887,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1776,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1665,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1221,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1341.99,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1576.2,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1554,,,percent of total billed charges,,,,,,1332,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1887,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2220,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,999,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1887,,,percent of total billed charges,,,,,,1443,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP DHS SS 95DG 10H 25 X 178,27707,CDM,0278,RC,,,,,,outpatient,facility,,,2220,2220,129.72,2220,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1887,,,percent of total billed charges,,,,,,666,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,421.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,421.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1665,,,percent of total billed charges,,,,,,1554,,,percent of total billed charges,,,,,,1554,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1443,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2220,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1554,,,percent of total billed charges,,,,,,1221,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,1548.45,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1576.2,,,percent of total billed charges,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1554,,,percent of total billed charges,,,,,,1332,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1887,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2220,,,percent of total billed charges,,,,,,999,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2220,,,fee schedule,,,,,,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,2220,,,percent of total billed charges,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1221,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2220,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1887,,,percent of total billed charges,,,,,,1665,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCS 95DG 210M 12H,27711,CDM,0278,RC,,,,,,inpatient,facility,,,2506,2506,1127.7,2506,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2130.1,,,percent of total billed charges,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2004.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1879.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1378.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1514.88,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1779.26,,,percent of total billed charges,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1754.2,,,percent of total billed charges,,,,,,1503.6,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2130.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2506,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2506,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1127.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2130.1,,,percent of total billed charges,,,,,,1628.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCS 95DG 210M 12H,27711,CDM,0278,RC,,,,,,outpatient,facility,,,2506,2506,129.72,2506,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2130.1,,,percent of total billed charges,,,,,,751.8,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,476.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,476.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1879.5,,,percent of total billed charges,,,,,,1754.2,,,percent of total billed charges,,,,,,1754.2,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1628.9,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2506,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1754.2,,,percent of total billed charges,,,,,,1378.3,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,,percent of total billed charges,,,,,,1747.94,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1779.26,,,percent of total billed charges,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1754.2,,,percent of total billed charges,,,,,,1503.6,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2130.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,,percent of total billed charges,,,,,,2506,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2506,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,,,,,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2506,,,percent of total billed charges,,,,,,1127.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1879.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2506,,,fee schedule,,,,,,2506,,,percent of total billed charges,,,,,,2506,,,percent of total billed charges,,,,,,2506,,,percent of total billed charges,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1378.3,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2506,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2130.1,,,percent of total billed charges,,,,,,1879.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE SYN DCP DHS SS 95DG 16H 25 X 274,27714,CDM,0278,RC,,,,,,inpatient,facility,,,2673,2673,1202.85,2673,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2272.05,,,percent of total billed charges,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2138.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2004.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1470.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1615.83,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1897.83,,,percent of total billed charges,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1871.1,,,percent of total billed charges,,,,,,1603.8,,,percent of total billed charges,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2272.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1470.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2673,,,percent of total billed charges,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2004.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2673,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1202.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2272.05,,,percent of total billed charges,,,,,,1737.45,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE SYN DCP DHS SS 95DG 16H 25 X 274,27714,CDM,0278,RC,,,,,,outpatient,facility,,,2673,2673,129.72,2673,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2272.05,,,percent of total billed charges,,,,,,801.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,507.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,507.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2004.75,,,percent of total billed charges,,,,,,1871.1,,,percent of total billed charges,,,,,,1871.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1737.45,,,percent of total billed charges,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2673,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1871.1,,,percent of total billed charges,,,,,,1470.15,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2673,,,percent of total billed charges,,,,,,1864.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1897.83,,,percent of total billed charges,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1871.1,,,percent of total billed charges,,,,,,1603.8,,,percent of total billed charges,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2272.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1470.15,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2673,,,percent of total billed charges,,,,,,2673,,,percent of total billed charges,,,,,,1470.15,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2673,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2673,,,percent of total billed charges,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2004.75,,,percent of total billed charges,,,,,,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2673,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2673,,,percent of total billed charges,,,,,,1202.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2004.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2673,,,fee schedule,,,,,,2673,,,percent of total billed charges,,,,,,2673,,,percent of total billed charges,,,,,,2673,,,percent of total billed charges,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1470.15,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2673,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2272.05,,,percent of total billed charges,,,,,,2004.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR KNEE SCORPIO CR M S LFIT LT 7 NC,27725,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR KNEE SCORPIO CR M S LFIT LT 7 NC,27725,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEMUR STR KNEE SCORPIO CR M S LFIT RT 7 NC,27726,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEMUR STR KNEE SCORPIO CR M S LFIT RT 7 NC,27726,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP RELIANCE PF 0 NC,27750,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP RELIANCE PF 0 NC,27750,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP RELIANCE PF 1 NC,27751,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP RELIANCE PF 1 NC,27751,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP RELIANCE PF 2 NC,27752,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP RELIANCE PF 2 NC,27752,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP RELIANCE PF 3 NC,27753,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP RELIANCE PF 3 NC,27753,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP RELIANCE PF 4 NC,27754,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP RELIANCE PF 4 NC,27754,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP RELIANCE PF 5 NC,27755,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP RELIANCE PF 5 NC,27755,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP RELIANCE PF 6 NC,27756,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP RELIANCE PF 6 NC,27756,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
STEM STR HIP RELIANCE PF 7 NC,27757,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
STEM STR HIP RELIANCE PF 7 NC,27757,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CATH GUIDE IX XBRCA 7FR .078 X 100  i,27787,CDM,0272,RC,,,,,,inpatient,facility,,,529.2,529.2,238.14,529.2,,,,,,,,,,,,,,,,,,,,449.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,343.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,370.44,,,percent of total billed charges,,,,,,317.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,449.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,529.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,238.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,449.82,,,percent of total billed charges,,,,,,,,,,,,,,
CATH GUIDE IX XBRCA 7FR .078 X 100  i,27787,CDM,0272,RC,,,,,,outpatient,facility,,,529.2,529.2,100.55,1016,,343.98,,,percent of total billed charges,,,,,,,,,,,,,,,449.82,,,percent of total billed charges,,,,,,158.76,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,248.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,100.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,100.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,396.9,,,percent of total billed charges,,,,,,370.44,,,percent of total billed charges,,,,,,370.44,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,343.98,,,percent of total billed charges,,,,,,127.01,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",357.21,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,529.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,222.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",370.44,,,percent of total billed charges,,,,,,,,,,,,,,,529.2,,,percent of total billed charges,,,,,,369.12,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,375.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,370.44,,,percent of total billed charges,,,,,,317.52,,,percent of total billed charges,,,,,,238.14,,,percent of total billed charges,,,,,,,,,,,,,,,449.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.2,,,percent of total billed charges,,,,,,529.2,,,percent of total billed charges,,,,,,227.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,529.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,529.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.9,,,percent of total billed charges,,,,,,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,529.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,529.2,,,percent of total billed charges,,,,,,238.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.2,,,fee schedule,,,,,,529.2,,,percent of total billed charges,,,,,,529.2,,,percent of total billed charges,,,,,,529.2,,,percent of total billed charges,,,,,,254.02,,,percent of total billed charges,,,,,,,,,,,,,,,312.23,,,percent of total billed charges,,,,,,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,529.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,449.82,,,percent of total billed charges,,,,,,396.9,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ENDO STITCH 10M 173016  i,27791,CDM,0272,RC,,,,,,inpatient,facility,,,386.33,386.33,173.85,386.33,,,,,,,,,,,,,,,,,,,,328.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,289.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,270.43,,,percent of total billed charges,,,,,,231.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,328.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,289.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,173.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.38,,,percent of total billed charges,,,,,,,,,,,,,,
ENDO STITCH 10M 173016  i,27791,CDM,0272,RC,,,,,,outpatient,facility,,,386.33,386.33,73.4,1016,,251.11,,,percent of total billed charges,,,,,,,,,,,,,,,328.38,,,percent of total billed charges,,,,,,115.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,181.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,73.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,289.74,,,percent of total billed charges,,,,,,270.43,,,percent of total billed charges,,,,,,270.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,251.11,,,percent of total billed charges,,,,,,92.72,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",260.77,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,386.33,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,162.26,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",270.43,,,percent of total billed charges,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,269.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,274.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,270.43,,,percent of total billed charges,,,,,,231.8,,,percent of total billed charges,,,,,,173.85,,,percent of total billed charges,,,,,,,,,,,,,,,328.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,386.33,,,percent of total billed charges,,,,,,166.12,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,386.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,289.75,,,percent of total billed charges,,,,,,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,386.33,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,386.33,,,percent of total billed charges,,,,,,173.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,289.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.33,,,fee schedule,,,,,,386.33,,,percent of total billed charges,,,,,,386.33,,,percent of total billed charges,,,,,,386.33,,,percent of total billed charges,,,,,,185.44,,,percent of total billed charges,,,,,,,,,,,,,,,227.93,,,percent of total billed charges,,,,,,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,386.33,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,328.38,,,percent of total billed charges,,,,,,289.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRSG TEGADERM TRANSP STRL 8 X 12  i,27794,CDM,0272,RC,,,,,,inpatient,facility,,,5.84,5.84,2.63,5.84,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,3.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,
DRSG TEGADERM TRANSP STRL 8 X 12  i,27794,CDM,0272,RC,,,,,,outpatient,facility,,,5.84,5.84,1.11,1016,,3.8,,,percent of total billed charges,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,1.75,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.38,,,percent of total billed charges,,,,,,4.09,,,percent of total billed charges,,,,,,4.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.8,,,percent of total billed charges,,,,,,1.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.94,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.84,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.45,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.09,,,percent of total billed charges,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,4.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,4.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.09,,,percent of total billed charges,,,,,,3.5,,,percent of total billed charges,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,4.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,5.84,,,percent of total billed charges,,,,,,2.51,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,,,,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.84,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.84,,,percent of total billed charges,,,,,,2.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.84,,,fee schedule,,,,,,5.84,,,percent of total billed charges,,,,,,5.84,,,percent of total billed charges,,,,,,5.84,,,percent of total billed charges,,,,,,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,3.45,,,percent of total billed charges,,,,,,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.96,,,percent of total billed charges,,,,,,4.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX 5percent INJ 1000ML 2B0064  i,278,CDM,0258,RC,,,,,,inpatient,facility,,,5.95,5.95,2.68,5.95,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.17,,,percent of total billed charges,,,,,,3.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent INJ 1000ML 2B0064  i,278,CDM,0258,RC,,,,,,outpatient,facility,,,5.95,5.95,1.13,1016,,3.87,,,percent of total billed charges,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,1.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.47,,,percent of total billed charges,,,,,,4.17,,,percent of total billed charges,,,,,,4.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.87,,,percent of total billed charges,,,,,,1.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,5.95,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.5,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.17,,,percent of total billed charges,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,,,,4.15,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,4.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.17,,,percent of total billed charges,,,,,,3.57,,,percent of total billed charges,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,5.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,,,,5.95,,,percent of total billed charges,,,,,,2.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.95,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,5.95,,,percent of total billed charges,,,,,,2.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.95,,,fee schedule,,,,,,5.95,,,percent of total billed charges,,,,,,5.95,,,percent of total billed charges,,,,,,5.95,,,percent of total billed charges,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,3.51,,,percent of total billed charges,,,,,,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,5.95,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.06,,,percent of total billed charges,,,,,,4.46,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SYN FEM CANN TI STRL 10 X 380,27806,CDM,0278,RC,,,,,,inpatient,facility,,,2765.92,2765.92,1244.66,2765.92,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2351.03,,,percent of total billed charges,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2212.74,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2074.44,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1521.26,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1672,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",1963.8,,,percent of total billed charges,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1936.14,,,percent of total billed charges,,,,,,1659.55,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2351.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2765.92,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2074.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2765.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1244.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2351.03,,,percent of total billed charges,,,,,,1797.85,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SYN FEM CANN TI STRL 10 X 380,27806,CDM,0278,RC,,,,,,outpatient,facility,,,2765.92,2765.92,129.72,2765.92,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2351.03,,,percent of total billed charges,,,,,,829.78,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,525.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,525.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2074.44,,,percent of total billed charges,,,,,,1936.14,,,percent of total billed charges,,,,,,1936.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1797.85,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,2765.92,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1936.14,,,percent of total billed charges,,,,,,1521.26,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,,percent of total billed charges,,,,,,1929.23,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1963.8,,,percent of total billed charges,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1936.14,,,percent of total billed charges,,,,,,1659.55,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2351.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,,percent of total billed charges,,,,,,2765.92,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,2765.92,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2074.44,,,percent of total billed charges,,,,,,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,2765.92,,,percent of total billed charges,,,,,,1244.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2074.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2765.92,,,fee schedule,,,,,,2765.92,,,percent of total billed charges,,,,,,2765.92,,,percent of total billed charges,,,,,,2765.92,,,percent of total billed charges,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1521.26,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2765.92,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2351.03,,,percent of total billed charges,,,,,,2074.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
END CAP SYN TI EXT 15 X 10,27807,CDM,0278,RC,,,,,,inpatient,facility,,,378.84,378.84,170.48,378.84,,,,,,,,,,,,,,,,,,,,322.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,284.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,229.01,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",268.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,265.19,,,percent of total billed charges,,,,,,227.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,322.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,170.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,322.01,,,percent of total billed charges,,,,,,246.25,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
END CAP SYN TI EXT 15 X 10,27807,CDM,0278,RC,,,,,,outpatient,facility,,,378.84,378.84,71.98,378.84,,246.25,,,percent of total billed charges,,,,,,,,,,,,,,,322.01,,,percent of total billed charges,,,,,,113.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,178.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.36,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,71.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,71.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,208.36,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,208.36,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,208.36,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,284.13,,,percent of total billed charges,,,,,,265.19,,,percent of total billed charges,,,,,,265.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,246.25,,,percent of total billed charges,,,,,,90.92,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,378.84,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,159.11,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",265.19,,,percent of total billed charges,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,264.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,268.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,265.19,,,percent of total billed charges,,,,,,227.3,,,percent of total billed charges,,,,,,170.48,,,percent of total billed charges,,,,,,,,,,,,,,,322.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,378.84,,,percent of total billed charges,,,,,,162.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.13,,,percent of total billed charges,,,,,,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,378.84,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,378.84,,,percent of total billed charges,,,,,,170.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,,fee schedule,,,,,,378.84,,,percent of total billed charges,,,,,,378.84,,,percent of total billed charges,,,,,,378.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,378.84,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,322.01,,,percent of total billed charges,,,,,,284.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SLEEVE SYN LOCKING 130,27808,CDM,0278,RC,,,,,,inpatient,facility,,,706.2,706.2,317.79,706.2,,,,,,,,,,,,,,,,,,,,600.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,564.96,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,529.65,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.41,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,426.9,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",501.4,,,percent of total billed charges,,,,,,,,,,,,,,,388.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,494.34,,,percent of total billed charges,,,,,,423.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,600.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.41,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,388.41,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.2,,,percent of total billed charges,,,,,,388.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,529.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,706.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,317.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.27,,,percent of total billed charges,,,,,,459.03,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SLEEVE SYN LOCKING 130,27808,CDM,0278,RC,,,,,,outpatient,facility,,,706.2,706.2,129.72,706.2,,459.03,,,percent of total billed charges,,,,,,,,,,,,,,,600.27,,,percent of total billed charges,,,,,,211.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,331.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,134.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,134.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,388.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,388.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,388.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,529.65,,,percent of total billed charges,,,,,,494.34,,,percent of total billed charges,,,,,,494.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,459.03,,,percent of total billed charges,,,,,,388.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,706.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,296.6,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",494.34,,,percent of total billed charges,,,,,,388.41,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,706.2,,,percent of total billed charges,,,,,,492.57,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,501.4,,,percent of total billed charges,,,,,,,,,,,,,,,388.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,494.34,,,percent of total billed charges,,,,,,423.72,,,percent of total billed charges,,,,,,317.79,,,percent of total billed charges,,,,,,,,,,,,,,,600.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.41,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,706.2,,,percent of total billed charges,,,,,,706.2,,,percent of total billed charges,,,,,,388.41,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,706.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,706.2,,,percent of total billed charges,,,,,,388.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,529.65,,,percent of total billed charges,,,,,,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,706.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,706.2,,,percent of total billed charges,,,,,,317.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,529.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,388.41,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,706.2,,,fee schedule,,,,,,706.2,,,percent of total billed charges,,,,,,706.2,,,percent of total billed charges,,,,,,706.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,706.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,600.27,,,percent of total billed charges,,,,,,529.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT DURAGUARD BOVINE 10 X 16  i,27809,CDM,0278,RC,,,,,,inpatient,facility,,,1112,1112,500.4,1112,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,945.2,,,percent of total billed charges,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,889.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,834,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,611.6,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,672.2,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",789.52,,,percent of total billed charges,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,778.4,,,percent of total billed charges,,,,,,667.2,,,percent of total billed charges,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,945.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.6,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1112,,,percent of total billed charges,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,834,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1112,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,500.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.2,,,percent of total billed charges,,,,,,722.8,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT DURAGUARD BOVINE 10 X 16  i,27809,CDM,0278,RC,,,,,,outpatient,facility,,,1112,1112,129.72,1112,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,945.2,,,percent of total billed charges,,,,,,333.6,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,211.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,211.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,834,,,percent of total billed charges,,,,,,778.4,,,percent of total billed charges,,,,,,778.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,722.8,,,percent of total billed charges,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1112,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,778.4,,,percent of total billed charges,,,,,,611.6,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1112,,,percent of total billed charges,,,,,,775.62,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,789.52,,,percent of total billed charges,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,778.4,,,percent of total billed charges,,,,,,667.2,,,percent of total billed charges,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,945.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,611.6,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1112,,,percent of total billed charges,,,,,,1112,,,percent of total billed charges,,,,,,611.6,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1112,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1112,,,percent of total billed charges,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,834,,,percent of total billed charges,,,,,,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1112,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1112,,,percent of total billed charges,,,,,,500.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,834,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1112,,,fee schedule,,,,,,1112,,,percent of total billed charges,,,,,,1112,,,percent of total billed charges,,,,,,1112,,,percent of total billed charges,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,611.6,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1112,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,945.2,,,percent of total billed charges,,,,,,834,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
GRAFT DURAGUARD BOVINE 6 X 8  i,27810,CDM,0278,RC,,,,,,inpatient,facility,,,1296.96,1296.96,583.63,1296.96,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1102.42,,,percent of total billed charges,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1037.57,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,972.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,713.33,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,784.01,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",920.84,,,percent of total billed charges,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,907.87,,,percent of total billed charges,,,,,,778.18,,,percent of total billed charges,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1102.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,713.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.96,,,percent of total billed charges,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,972.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1296.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,583.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1102.42,,,percent of total billed charges,,,,,,843.02,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
GRAFT DURAGUARD BOVINE 6 X 8  i,27810,CDM,0278,RC,,,,,,outpatient,facility,,,1296.96,1296.96,129.72,1296.96,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1102.42,,,percent of total billed charges,,,,,,389.09,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,246.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,246.42,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,972.72,,,percent of total billed charges,,,,,,907.87,,,percent of total billed charges,,,,,,907.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,843.02,,,percent of total billed charges,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1296.96,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,907.87,,,percent of total billed charges,,,,,,713.33,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1296.96,,,percent of total billed charges,,,,,,904.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,920.84,,,percent of total billed charges,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,907.87,,,percent of total billed charges,,,,,,778.18,,,percent of total billed charges,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1102.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,713.33,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1296.96,,,percent of total billed charges,,,,,,1296.96,,,percent of total billed charges,,,,,,713.33,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.96,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1296.96,,,percent of total billed charges,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,972.72,,,percent of total billed charges,,,,,,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1296.96,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1296.96,,,percent of total billed charges,,,,,,583.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,972.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1296.96,,,fee schedule,,,,,,1296.96,,,percent of total billed charges,,,,,,1296.96,,,percent of total billed charges,,,,,,1296.96,,,percent of total billed charges,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,713.33,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1296.96,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1102.42,,,percent of total billed charges,,,,,,972.72,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
LEAD MED SUREFIX 52CM 5072,27812,CDM,0275,RC,,,,,,inpatient,facility,,,1050,1050,472.5,1050,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,892.5,,,percent of total billed charges,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,577.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,745.5,,,percent of total billed charges,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,735,,,percent of total billed charges,,,,,,630,,,percent of total billed charges,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,892.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1050,,,percent of total billed charges,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1050,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,472.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,892.5,,,percent of total billed charges,,,,,,,,,,,,,,
LEAD MED SUREFIX 52CM 5072,27812,CDM,0275,RC,,,,,,outpatient,facility,,,1050,1050,129.72,1050,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,892.5,,,percent of total billed charges,,,,,,315,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,199.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,199.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,787.5,,,percent of total billed charges,,,,,,735,,,percent of total billed charges,,,,,,735,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,682.5,,,percent of total billed charges,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1050,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,735,,,percent of total billed charges,,,,,,577.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1050,,,percent of total billed charges,,,,,,732.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,745.5,,,percent of total billed charges,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,735,,,percent of total billed charges,,,,,,630,,,percent of total billed charges,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,892.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1050,,,percent of total billed charges,,,,,,1050,,,percent of total billed charges,,,,,,577.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1050,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1050,,,percent of total billed charges,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1050,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1050,,,percent of total billed charges,,,,,,472.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1050,,,fee schedule,,,,,,1050,,,percent of total billed charges,,,,,,1050,,,percent of total billed charges,,,,,,1050,,,percent of total billed charges,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,577.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1050,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,892.5,,,percent of total billed charges,,,,,,787.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BARRIER SEPRA FILM ADHESION 3X5,27826154,CDM,0278,RC,C1765,HCPCS,,,,inpatient,facility,,,1310.4,1310.4,589.68,1310.4,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1113.84,,,percent of total billed charges,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1048.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,982.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,720.72,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,792.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",930.38,,,percent of total billed charges,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,917.28,,,percent of total billed charges,,,,,,786.24,,,percent of total billed charges,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1113.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.72,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1310.4,,,percent of total billed charges,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,982.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1310.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,589.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1113.84,,,percent of total billed charges,,,,,,851.76,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC BARRIER SEPRA FILM ADHESION 3X5,27826154,CDM,0278,RC,C1765,HCPCS,,,,outpatient,facility,,,1310.4,1310.4,129.72,1310.4,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1113.84,,,percent of total billed charges,,,,,,393.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,884.52,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,248.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,248.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,982.8,,,percent of total billed charges,,,,,,917.28,,,percent of total billed charges,,,,,,917.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,851.76,,,percent of total billed charges,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,884.52,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1310.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,917.28,,,percent of total billed charges,,,,,,720.72,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1310.4,,,percent of total billed charges,,,,,,914,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,930.38,,,percent of total billed charges,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,917.28,,,percent of total billed charges,,,,,,786.24,,,percent of total billed charges,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1113.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.72,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1310.4,,,percent of total billed charges,,,,,,1310.4,,,percent of total billed charges,,,,,,720.72,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1310.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1310.4,,,percent of total billed charges,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,982.8,,,percent of total billed charges,,,,,,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1310.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1310.4,,,percent of total billed charges,,,,,,589.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,982.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1310.4,,,fee schedule,,,,,,1310.4,,,percent of total billed charges,,,,,,1310.4,,,percent of total billed charges,,,,,,1310.4,,,percent of total billed charges,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,720.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1310.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1113.84,,,percent of total billed charges,,,,,,982.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BARRIER SEPRA FILM ADHESION 5X6,27854563,CDM,0278,RC,C1765,HCPCS,,,,inpatient,facility,,,534.56,534.56,240.55,534.56,,,,,,,,,,,,,,,,,,,,454.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.65,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,400.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.14,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",379.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,374.19,,,percent of total billed charges,,,,,,320.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,454.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.01,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,294.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,534.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,240.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,454.38,,,percent of total billed charges,,,,,,347.46,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC BARRIER SEPRA FILM ADHESION 5X6,27854563,CDM,0278,RC,C1765,HCPCS,,,,outpatient,facility,,,534.56,534.56,101.57,534.56,,347.46,,,percent of total billed charges,,,,,,,,,,,,,,,454.38,,,percent of total billed charges,,,,,,160.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,251.24,,,percent of total billed charges,,,,,,360.83,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,101.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,101.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,294.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,294.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,294.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,400.92,,,percent of total billed charges,,,,,,374.19,,,percent of total billed charges,,,,,,374.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,347.46,,,percent of total billed charges,,,,,,294.01,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,360.83,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,534.56,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,224.52,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",374.19,,,percent of total billed charges,,,,,,,,,,,,,,,534.56,,,percent of total billed charges,,,,,,372.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,379.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,374.19,,,percent of total billed charges,,,,,,320.74,,,percent of total billed charges,,,,,,240.55,,,percent of total billed charges,,,,,,,,,,,,,,,454.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,294.01,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,534.56,,,percent of total billed charges,,,,,,534.56,,,percent of total billed charges,,,,,,294.01,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,534.56,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,534.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.92,,,percent of total billed charges,,,,,,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,534.56,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,534.56,,,percent of total billed charges,,,,,,240.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.56,,,fee schedule,,,,,,534.56,,,percent of total billed charges,,,,,,534.56,,,percent of total billed charges,,,,,,534.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,534.56,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,454.38,,,percent of total billed charges,,,,,,400.92,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BRACHYTXSTRANDED1 125,27876301,CDM,0278,RC,C2638,HCPCS,,,,inpatient,facility,,,91,91,40.95,91,,,,,,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,68.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.01,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.7,,,percent of total billed charges,,,,,,54.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,40.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,59.15,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC BRACHYTXSTRANDED1 125,27876301,CDM,0278,RC,C2638,HCPCS,,,,outpatient,facility,,,91,91,21.84,138.8,,59.15,,,percent of total billed charges,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,42.77,,,percent of total billed charges,,,,,,61.43,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,50.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,50.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,50.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.25,,,percent of total billed charges,,,,,,63.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.15,,,percent of total billed charges,,,,,,21.84,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",61.43,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,91,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,38.22,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",63.7,,,percent of total billed charges,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,63.47,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,63.7,,,percent of total billed charges,,,,,,54.6,,,percent of total billed charges,,,,,,40.95,,,percent of total billed charges,,,,,,,,,,,,,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,91,,,percent of total billed charges,,,,,,39.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,91,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,91,,,percent of total billed charges,,,,,,40.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.26,,,fee schedule,,,,,,91,,,percent of total billed charges,,,,,,91,,,percent of total billed charges,,,,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,91,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,77.35,,,percent of total billed charges,,,,,,68.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BRACHYTXSTRANDED1 125,27876301,CDM,0278,RC,C2638,HCPCS,02638,APC,,outpatient,facility,,,91,91,29.97,85.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,44.07,,,fee schedule,,,,,,81.32,,,fee schedule,,,,,,85.33,,,fee schedule,,,,,,53.6,,,fee schedule,,,,,,34.7,,,fee schedule,,,,,,75.81,,,fee schedule,,,,,,,,,,,,,,,35.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,42.31,,,fee schedule,,,,,,35.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.26,,,fee schedule,,,,,,35.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.26,,,fee schedule,,,,,,,,,,,,,,,52.89,,,fee schedule,,,,,,35.26,,,fee schedule,,,,,,,,,,,,,,,35.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.73,,,fee schedule,,,,,,37.16,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",35.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.7,,,fee schedule,,,,,,35.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,35.26,,,fee schedule,,,,,,61.71,,,fee schedule,,,,,,34.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.07,,,fee schedule,,,,,,,,,,,,,,,44.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.26,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTXSTRANDED1 125,27876301,CDM,0278,RC,C2638,HCPCS,335,EAPG,,outpatient,facility,,,91,91,147.73,165.46,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.5,,,fee schedule,,,,,,,,,,,,,,,155.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,165.46,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTXSTRANDEDP 103,27876303,CDM,0278,RC,C2640,HCPCS,,,,inpatient,facility,,,161.2,161.2,72.54,161.2,,,,,,,,,,,,,,,,,,,,137.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.96,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,120.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.45,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",114.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,112.84,,,percent of total billed charges,,,,,,96.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,161.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,72.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.02,,,percent of total billed charges,,,,,,104.78,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC BRACHYTXSTRANDEDP 103,27876303,CDM,0278,RC,C2640,HCPCS,,,,outpatient,facility,,,161.2,161.2,38.69,161.2,,104.78,,,percent of total billed charges,,,,,,,,,,,,,,,137.02,,,percent of total billed charges,,,,,,,,,,,,,,,75.76,,,percent of total billed charges,,,,,,108.81,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,88.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,88.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,88.66,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,120.9,,,percent of total billed charges,,,,,,112.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.78,,,percent of total billed charges,,,,,,38.69,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.81,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,161.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,67.7,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",112.84,,,percent of total billed charges,,,,,,,,,,,,,,,161.2,,,percent of total billed charges,,,,,,112.44,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,114.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,112.84,,,percent of total billed charges,,,,,,96.72,,,percent of total billed charges,,,,,,72.54,,,percent of total billed charges,,,,,,,,,,,,,,,137.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.2,,,percent of total billed charges,,,,,,161.2,,,percent of total billed charges,,,,,,69.32,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,161.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,161.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.9,,,percent of total billed charges,,,,,,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,161.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,161.2,,,percent of total billed charges,,,,,,72.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.26,,,fee schedule,,,,,,161.2,,,percent of total billed charges,,,,,,161.2,,,percent of total billed charges,,,,,,161.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,161.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,137.02,,,percent of total billed charges,,,,,,120.9,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BRACHYTXSTRANDEDP 103,27876303,CDM,0278,RC,C2640,HCPCS,02640,APC,,outpatient,facility,,,161.2,161.2,75.02,213.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,110.33,,,fee schedule,,,,,,203.55,,,fee schedule,,,,,,213.59,,,fee schedule,,,,,,134.16,,,fee schedule,,,,,,86.85,,,fee schedule,,,,,,189.76,,,fee schedule,,,,,,,,,,,,,,,88.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,88.26,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.02,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,105.91,,,fee schedule,,,,,,90.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.26,,,fee schedule,,,,,,88.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.26,,,fee schedule,,,,,,,,,,,,,,,132.39,,,fee schedule,,,,,,88.26,,,fee schedule,,,,,,,,,,,,,,,88.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.44,,,fee schedule,,,,,,93.02,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",88.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.85,,,fee schedule,,,,,,88.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,88.26,,,fee schedule,,,,,,154.46,,,fee schedule,,,,,,86.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.33,,,fee schedule,,,,,,,,,,,,,,,110.33,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.26,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.85,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTXSTRANDEDP 103,27876303,CDM,0278,RC,C2640,HCPCS,336,EAPG,,outpatient,facility,,,161.2,161.2,1708.41,1913.42,,,,,,,,,,,1708.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1708.41,,,fee schedule,,,,,,,,,,,,,,,1708.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1879.25,,,fee schedule,,,,,,,,,,,,,,,1793.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,1913.42,,,fee schedule,,,,,,,,,,,,,,,1708.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTXSTRANDEDC 131,27876305,CDM,0278,RC,C2642,HCPCS,,,,inpatient,facility,,,162.24,162.24,73.01,162.24,,,,,,,,,,,,,,,,,,,,137.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.79,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,121.68,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.07,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",115.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.57,,,percent of total billed charges,,,,,,97.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,137.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,73.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.9,,,percent of total billed charges,,,,,,105.46,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC BRACHYTXSTRANDEDC 131,27876305,CDM,0278,RC,C2642,HCPCS,,,,outpatient,facility,,,162.24,162.24,38.94,162.24,,105.46,,,percent of total billed charges,,,,,,,,,,,,,,,137.9,,,percent of total billed charges,,,,,,,,,,,,,,,76.25,,,percent of total billed charges,,,,,,109.51,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,89.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,89.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,89.23,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,121.68,,,percent of total billed charges,,,,,,113.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,105.46,,,percent of total billed charges,,,,,,38.94,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",109.51,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,162.24,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.14,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",113.57,,,percent of total billed charges,,,,,,,,,,,,,,,162.24,,,percent of total billed charges,,,,,,113.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,115.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,113.57,,,percent of total billed charges,,,,,,97.34,,,percent of total billed charges,,,,,,73.01,,,percent of total billed charges,,,,,,,,,,,,,,,137.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.24,,,percent of total billed charges,,,,,,162.24,,,percent of total billed charges,,,,,,69.76,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,162.24,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,162.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.68,,,percent of total billed charges,,,,,,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,162.24,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,162.24,,,percent of total billed charges,,,,,,73.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.11,,,fee schedule,,,,,,162.24,,,percent of total billed charges,,,,,,162.24,,,percent of total billed charges,,,,,,162.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,162.24,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,137.9,,,percent of total billed charges,,,,,,121.68,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BRACHYTXSTRANDEDC 131,27876305,CDM,0278,RC,C2642,HCPCS,02642,APC,,outpatient,facility,,,162.24,162.24,101.24,288.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,148.89,,,fee schedule,,,,,,274.7,,,fee schedule,,,,,,288.25,,,fee schedule,,,,,,181.05,,,fee schedule,,,,,,117.2,,,fee schedule,,,,,,256.09,,,fee schedule,,,,,,,,,,,,,,,119.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,119.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,101.24,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,142.93,,,fee schedule,,,,,,121.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.11,,,fee schedule,,,,,,119.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.11,,,fee schedule,,,,,,,,,,,,,,,178.67,,,fee schedule,,,,,,119.11,,,fee schedule,,,,,,,,,,,,,,,119.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.45,,,fee schedule,,,,,,125.54,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",119.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.2,,,fee schedule,,,,,,119.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,119.11,,,fee schedule,,,,,,208.44,,,fee schedule,,,,,,117.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,148.89,,,fee schedule,,,,,,,,,,,,,,,148.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.11,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTXSTRANDEDC 131,27876305,CDM,0278,RC,C2642,HCPCS,336,EAPG,,outpatient,facility,,,162.24,162.24,1708.41,1913.42,,,,,,,,,,,1708.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1708.41,,,fee schedule,,,,,,,,,,,,,,,1708.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1879.25,,,fee schedule,,,,,,,,,,,,,,,1793.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,1913.42,,,fee schedule,,,,,,,,,,,,,,,1708.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC TISSUE MARKERIMPLANTABLE,27876320,CDM,0278,RC,A4648,HCPCS,,,,inpatient,facility,,,143.52,143.52,64.58,143.52,,,,,,,,,,,,,,,,,,,,121.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.82,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,107.64,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.76,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",101.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,100.46,,,percent of total billed charges,,,,,,86.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,121.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,143.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,64.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,121.99,,,percent of total billed charges,,,,,,93.29,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC TISSUE MARKERIMPLANTABLE,27876320,CDM,0278,RC,A4648,HCPCS,,,,outpatient,facility,,,143.52,143.52,27.27,143.52,,93.29,,,percent of total billed charges,,,,,,,,,,,,,,,121.99,,,percent of total billed charges,,,,,,43.06,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,67.45,,,percent of total billed charges,,,,,,96.88,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,27.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,27.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,78.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,78.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,143.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,78.94,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,107.64,,,percent of total billed charges,,,,,,100.46,,,percent of total billed charges,,,,,,100.46,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,93.29,,,percent of total billed charges,,,,,,34.44,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",96.88,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,143.52,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,60.28,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,36.61,36.61,36.61,1 through 10,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",100.46,,,percent of total billed charges,,,,,,,,,,,,,,,143.52,,,percent of total billed charges,,,,,,100.11,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,101.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,100.46,,,percent of total billed charges,,,,,,86.11,,,percent of total billed charges,,,,,,64.58,,,percent of total billed charges,,,,,,,,,,,,,,,121.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.52,,,percent of total billed charges,,,,,,143.52,,,percent of total billed charges,,,,,,61.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,143.52,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,143.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.64,,,percent of total billed charges,,,,,,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,service not payable,143.52,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,service not payable,143.52,,,percent of total billed charges,,,,,,64.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.52,,,fee schedule,,,,,,143.52,,,percent of total billed charges,,,,,,143.52,,,percent of total billed charges,,,,,,143.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,143.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,143.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,121.99,,,percent of total billed charges,,,,,,107.64,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SEEDNON HDR IR 192,27894060,CDM,0278,RC,C1719,HCPCS,,,,inpatient,facility,,,98.8,98.8,44.46,98.8,,,,,,,,,,,,,,,,,,,,83.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.04,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,74.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.72,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",70.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.16,,,percent of total billed charges,,,,,,59.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,83.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.98,,,percent of total billed charges,,,,,,64.22,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC SEEDNON HDR IR 192,27894060,CDM,0278,RC,C1719,HCPCS,,,,outpatient,facility,,,98.8,98.8,23.71,908.7,,64.22,,,percent of total billed charges,,,,,,,,,,,,,,,83.98,,,percent of total billed charges,,,,,,,,,,,,,,,46.44,,,percent of total billed charges,,,,,,66.69,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.34,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,54.34,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,54.34,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,54.34,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,74.1,,,percent of total billed charges,,,,,,69.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.22,,,percent of total billed charges,,,,,,23.71,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",66.69,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,98.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,41.5,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",69.16,,,percent of total billed charges,,,,,,,,,,,,,,,98.8,,,percent of total billed charges,,,,,,68.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,70.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,69.16,,,percent of total billed charges,,,,,,59.28,,,percent of total billed charges,,,,,,44.46,,,percent of total billed charges,,,,,,,,,,,,,,,83.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.8,,,percent of total billed charges,,,,,,98.8,,,percent of total billed charges,,,,,,42.48,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,98.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.1,,,percent of total billed charges,,,,,,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,98.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,98.8,,,percent of total billed charges,,,,,,44.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,98.8,,,percent of total billed charges,,,,,,98.8,,,percent of total billed charges,,,,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,98.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,83.98,,,percent of total billed charges,,,,,,74.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC SEEDNON HDR IR 192,27894060,CDM,0278,RC,C1719,HCPCS,02647,APC,,outpatient,facility,,,98.8,98.8,772.39,2199.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1135.88,,,fee schedule,,,,,,2095.69,,,fee schedule,,,,,,2199.05,,,fee schedule,,,,,,1381.22,,,fee schedule,,,,,,894.16,,,fee schedule,,,,,,1953.7,,,fee schedule,,,,,,,,,,,,,,,908.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,908.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1090.44,,,fee schedule,,,,,,926.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,1363.05,,,fee schedule,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,972.31,,,fee schedule,,,,,,957.72,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",908.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.16,,,fee schedule,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,1590.23,,,fee schedule,,,,,,894.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1135.88,,,fee schedule,,,,,,,,,,,,,,,1135.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.7,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,954.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC SEEDNON HDR IR 192,27894060,CDM,0278,RC,C1719,HCPCS,335,EAPG,,outpatient,facility,,,98.8,98.8,147.73,165.46,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.5,,,fee schedule,,,,,,,,,,,,,,,155.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,165.46,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC SEEDPALLADIUM 103,27894061,CDM,0278,RC,C1720,HCPCS,,,,inpatient,facility,,,155.22,155.22,69.85,155.22,,,,,,,,,,,,,,,,,,,,131.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.18,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,116.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.83,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",110.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.65,,,percent of total billed charges,,,,,,93.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,131.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,155.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,69.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.94,,,percent of total billed charges,,,,,,100.89,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC SEEDPALLADIUM 103,27894061,CDM,0278,RC,C1720,HCPCS,,,,outpatient,facility,,,155.22,155.22,29.49,155.22,,100.89,,,percent of total billed charges,,,,,,,,,,,,,,,131.94,,,percent of total billed charges,,,,,,46.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,72.95,,,percent of total billed charges,,,,,,104.78,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.37,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,29.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,85.37,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,85.37,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,85.37,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,116.41,,,percent of total billed charges,,,,,,108.65,,,percent of total billed charges,,,,,,108.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,77.61,,,fee schedule,,,,,,77.61,,,fee schedule,,,,,,100.89,,,percent of total billed charges,,,,,,37.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",104.78,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.22,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,65.19,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",108.65,,,percent of total billed charges,,,,,,,,,,,,,,,155.22,,,percent of total billed charges,,,,,,108.27,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,110.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,108.65,,,percent of total billed charges,,,,,,93.13,,,percent of total billed charges,,,,,,69.85,,,percent of total billed charges,,,,,,,,,,,,,,,131.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.22,,,percent of total billed charges,,,,,,155.22,,,percent of total billed charges,,,,,,66.74,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,155.22,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,155.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.42,,,percent of total billed charges,,,,,,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.22,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,155.22,,,percent of total billed charges,,,,,,69.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.22,,,fee schedule,,,,,,155.22,,,percent of total billed charges,,,,,,155.22,,,percent of total billed charges,,,,,,155.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,155.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,131.94,,,percent of total billed charges,,,,,,116.42,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IRID IMP 2 3 99R11UP,27894067,CDM,0278,RC,C1719,HCPCS,,,,inpatient,facility,,,23.4,23.4,10.53,23.4,,,,,,,,,,,,,,,,,,,,19.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.72,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,17.55,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.15,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,16.38,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,19.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.89,,,percent of total billed charges,,,,,,15.21,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC IRID IMP 2 3 99R11UP,27894067,CDM,0278,RC,C1719,HCPCS,,,,outpatient,facility,,,23.4,23.4,5.62,908.7,,15.21,,,percent of total billed charges,,,,,,,,,,,,,,,19.89,,,percent of total billed charges,,,,,,,,,,,,,,,11,,,percent of total billed charges,,,,,,15.8,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,12.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,12.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,12.87,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,17.54,,,percent of total billed charges,,,,,,16.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.21,,,percent of total billed charges,,,,,,5.62,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",15.8,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,23.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,9.83,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",16.38,,,percent of total billed charges,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,16.32,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,16.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,16.38,,,percent of total billed charges,,,,,,14.04,,,percent of total billed charges,,,,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,19.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,23.4,,,percent of total billed charges,,,,,,10.06,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,23.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.55,,,percent of total billed charges,,,,,,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,23.4,,,percent of total billed charges,,,,,,10.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,23.4,,,percent of total billed charges,,,,,,23.4,,,percent of total billed charges,,,,,,23.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,23.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,19.89,,,percent of total billed charges,,,,,,17.55,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IRID IMP 2 3 99R11UP,27894067,CDM,0278,RC,C1719,HCPCS,02647,APC,,outpatient,facility,,,23.4,23.4,772.39,2199.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,945.05,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1135.88,,,fee schedule,,,,,,2095.69,,,fee schedule,,,,,,2199.05,,,fee schedule,,,,,,1381.22,,,fee schedule,,,,,,894.16,,,fee schedule,,,,,,1953.7,,,fee schedule,,,,,,,,,,,,,,,908.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,908.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.39,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1090.44,,,fee schedule,,,,,,926.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,1363.05,,,fee schedule,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,972.31,,,fee schedule,,,,,,957.72,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",908.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.16,,,fee schedule,,,,,,908.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,908.7,,,fee schedule,,,,,,1590.23,,,fee schedule,,,,,,894.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1135.88,,,fee schedule,,,,,,,,,,,,,,,1135.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,908.7,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,954.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC IRID IMP 2 3 99R11UP,27894067,CDM,0278,RC,C1719,HCPCS,335,EAPG,,outpatient,facility,,,23.4,23.4,147.73,165.46,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.5,,,fee schedule,,,,,,,,,,,,,,,155.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,165.46,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC IRD IMP 5 UPRA 11UP,27894073,CDM,0278,RC,C1717,HCPCS,,,,inpatient,facility,,,260,260,117,260,,,,,,,,,,,,,,,,,,,,221,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,195,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.17,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",184.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,182,,,percent of total billed charges,,,,,,156,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,221,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,260,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,117,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221,,,percent of total billed charges,,,,,,169,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC IRD IMP 5 UPRA 11UP,27894073,CDM,0278,RC,C1717,HCPCS,,,,outpatient,facility,,,260,260,62.4,357.49,,169,,,percent of total billed charges,,,,,,,,,,,,,,,221,,,percent of total billed charges,,,,,,,,,,,,,,,122.2,,,percent of total billed charges,,,,,,175.5,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,143,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,143,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,143,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195,,,percent of total billed charges,,,,,,182,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169,,,percent of total billed charges,,,,,,62.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",175.5,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,260,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,109.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",182,,,percent of total billed charges,,,,,,,,,,,,,,,260,,,percent of total billed charges,,,,,,181.35,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,184.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,182,,,percent of total billed charges,,,,,,156,,,percent of total billed charges,,,,,,117,,,percent of total billed charges,,,,,,,,,,,,,,,221,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260,,,percent of total billed charges,,,,,,260,,,percent of total billed charges,,,,,,111.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,260,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,260,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195,,,percent of total billed charges,,,,,,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,260,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,260,,,percent of total billed charges,,,,,,117,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,260,,,percent of total billed charges,,,,,,260,,,percent of total billed charges,,,,,,260,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,260,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,221,,,percent of total billed charges,,,,,,195,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC IRD IMP 5 UPRA 11UP,27894073,CDM,0278,RC,C1717,HCPCS,02646,APC,,outpatient,facility,,,260,260,303.87,865.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,446.86,,,fee schedule,,,,,,824.46,,,fee schedule,,,,,,865.13,,,fee schedule,,,,,,543.38,,,fee schedule,,,,,,351.77,,,fee schedule,,,,,,768.6,,,fee schedule,,,,,,,,,,,,,,,357.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,357.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,428.99,,,fee schedule,,,,,,364.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,536.24,,,fee schedule,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.51,,,fee schedule,,,,,,376.78,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",357.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.77,,,fee schedule,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,625.61,,,fee schedule,,,,,,351.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.86,,,fee schedule,,,,,,,,,,,,,,,446.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.49,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC IRD IMP 5 UPRA 11UP,27894073,CDM,0278,RC,C1717,HCPCS,335,EAPG,,outpatient,facility,,,260,260,147.73,165.46,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.5,,,fee schedule,,,,,,,,,,,,,,,155.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,165.46,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC SEED IODINE 125,27894082,CDM,0278,RC,C1718,HCPCS,,,,inpatient,facility,,,70.36,70.36,31.66,70.36,,,,,,,,,,,,,,,,,,,,59.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.29,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,52.77,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.53,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",49.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,49.25,,,percent of total billed charges,,,,,,42.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,59.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,70.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,31.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.81,,,percent of total billed charges,,,,,,45.73,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC SEED IODINE 125,27894082,CDM,0278,RC,C1718,HCPCS,,,,outpatient,facility,,,70.36,70.36,13.37,138.8,,45.73,,,percent of total billed charges,,,,,,,,,,,,,,,59.81,,,percent of total billed charges,,,,,,21.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,33.07,,,percent of total billed charges,,,,,,47.49,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,13.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,13.37,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,38.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,38.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,38.7,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,52.77,,,percent of total billed charges,,,,,,49.25,,,percent of total billed charges,,,,,,49.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.18,,,fee schedule,,,,,,35.18,,,fee schedule,,,,,,45.73,,,percent of total billed charges,,,,,,16.89,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",47.49,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,70.36,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,29.55,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",49.25,,,percent of total billed charges,,,,,,,,,,,,,,,70.36,,,percent of total billed charges,,,,,,49.08,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,49.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,49.25,,,percent of total billed charges,,,,,,42.22,,,percent of total billed charges,,,,,,31.66,,,percent of total billed charges,,,,,,,,,,,,,,,59.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.36,,,percent of total billed charges,,,,,,70.36,,,percent of total billed charges,,,,,,30.25,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,70.36,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,70.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.77,,,percent of total billed charges,,,,,,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.36,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,70.36,,,percent of total billed charges,,,,,,31.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.36,,,fee schedule,,,,,,70.36,,,percent of total billed charges,,,,,,70.36,,,percent of total billed charges,,,,,,70.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,70.36,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,59.81,,,percent of total billed charges,,,,,,52.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC GOLD 198 IMPLANT 1 25 SDS,27894085,CDM,0278,RC,C1716,HCPCS,,,,inpatient,facility,,,81.12,81.12,36.5,81.12,,,,,,,,,,,,,,,,,,,,68.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.9,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,60.84,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.04,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",57.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,56.78,,,percent of total billed charges,,,,,,48.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,68.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,81.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.95,,,percent of total billed charges,,,,,,52.73,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC GOLD 198 IMPLANT 1 25 SDS,27894085,CDM,0278,RC,C1716,HCPCS,,,,outpatient,facility,,,81.12,81.12,19.47,513.57,,52.73,,,percent of total billed charges,,,,,,,,,,,,,,,68.95,,,percent of total billed charges,,,,,,,,,,,,,,,38.13,,,percent of total billed charges,,,,,,54.76,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,44.62,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,44.62,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,44.62,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,60.84,,,percent of total billed charges,,,,,,56.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.73,,,percent of total billed charges,,,,,,19.47,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",54.76,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,81.12,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,34.07,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",56.78,,,percent of total billed charges,,,,,,,,,,,,,,,81.12,,,percent of total billed charges,,,,,,56.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,57.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,56.78,,,percent of total billed charges,,,,,,48.67,,,percent of total billed charges,,,,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,68.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.12,,,percent of total billed charges,,,,,,81.12,,,percent of total billed charges,,,,,,34.88,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,81.12,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,81.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.84,,,percent of total billed charges,,,,,,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.12,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,81.12,,,percent of total billed charges,,,,,,36.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.57,,,fee schedule,,,,,,81.12,,,percent of total billed charges,,,,,,81.12,,,percent of total billed charges,,,,,,81.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,81.12,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,68.95,,,percent of total billed charges,,,,,,60.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC GOLD 198 IMPLANT 1 25 SDS,27894085,CDM,0278,RC,C1716,HCPCS,02645,APC,,outpatient,facility,,,81.12,81.12,436.53,1242.84,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.11,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,641.96,,,fee schedule,,,,,,1184.42,,,fee schedule,,,,,,1242.84,,,fee schedule,,,,,,780.63,,,fee schedule,,,,,,505.35,,,fee schedule,,,,,,1104.18,,,fee schedule,,,,,,,,,,,,,,,513.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,513.57,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,616.28,,,fee schedule,,,,,,523.84,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.57,,,fee schedule,,,,,,513.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.57,,,fee schedule,,,,,,,,,,,,,,,770.36,,,fee schedule,,,,,,513.57,,,fee schedule,,,,,,,,,,,,,,,513.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,549.52,,,fee schedule,,,,,,541.28,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",513.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.35,,,fee schedule,,,,,,513.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,513.57,,,fee schedule,,,,,,898.75,,,fee schedule,,,,,,505.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.96,,,fee schedule,,,,,,,,,,,,,,,641.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,513.57,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,539.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC GOLD 198 IMPLANT 1 25 SDS,27894085,CDM,0278,RC,C1716,HCPCS,335,EAPG,,outpatient,facility,,,81.12,81.12,147.73,165.46,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.5,,,fee schedule,,,,,,,,,,,,,,,155.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,165.46,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTX SEEDHDR IR 192 SOURCE,27894133,CDM,0278,RC,C1717,HCPCS,,,,inpatient,facility,,,354.64,354.64,159.59,354.64,,,,,,,,,,,,,,,,,,,,301.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,283.71,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,265.98,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.38,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",251.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.25,,,percent of total billed charges,,,,,,212.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,301.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,354.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,159.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.44,,,percent of total billed charges,,,,,,230.52,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC BRACHYTX SEEDHDR IR 192 SOURCE,27894133,CDM,0278,RC,C1717,HCPCS,,,,outpatient,facility,,,354.64,354.64,85.11,357.49,,230.52,,,percent of total billed charges,,,,,,,,,,,,,,,301.44,,,percent of total billed charges,,,,,,,,,,,,,,,166.68,,,percent of total billed charges,,,,,,239.38,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,195.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,195.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,195.05,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,265.98,,,percent of total billed charges,,,,,,248.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.52,,,percent of total billed charges,,,,,,85.11,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",239.38,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.64,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,148.95,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",248.25,,,percent of total billed charges,,,,,,,,,,,,,,,354.64,,,percent of total billed charges,,,,,,247.36,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,251.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,248.25,,,percent of total billed charges,,,,,,212.78,,,percent of total billed charges,,,,,,159.59,,,percent of total billed charges,,,,,,,,,,,,,,,301.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.64,,,percent of total billed charges,,,,,,354.64,,,percent of total billed charges,,,,,,152.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,354.64,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,354.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.98,,,percent of total billed charges,,,,,,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.64,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,354.64,,,percent of total billed charges,,,,,,159.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,354.64,,,percent of total billed charges,,,,,,354.64,,,percent of total billed charges,,,,,,354.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,354.64,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,301.44,,,percent of total billed charges,,,,,,265.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BRACHYTX SEEDHDR IR 192 SOURCE,27894133,CDM,0278,RC,C1717,HCPCS,02646,APC,,outpatient,facility,,,354.64,354.64,303.87,865.13,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,446.86,,,fee schedule,,,,,,824.46,,,fee schedule,,,,,,865.13,,,fee schedule,,,,,,543.38,,,fee schedule,,,,,,351.77,,,fee schedule,,,,,,768.6,,,fee schedule,,,,,,,,,,,,,,,357.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,357.49,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.87,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,428.99,,,fee schedule,,,,,,364.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,536.24,,,fee schedule,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.51,,,fee schedule,,,,,,376.78,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",357.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.77,,,fee schedule,,,,,,357.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,357.49,,,fee schedule,,,,,,625.61,,,fee schedule,,,,,,351.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.86,,,fee schedule,,,,,,,,,,,,,,,446.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.49,,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ",other,,,,0,"Group (Sum Of):   Is:    Daily Charge Grouping:  Event properties: UB Lines with Table Code(s): [SOLIS BRIDGE APPT REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: Detail Charges with Revenue Code(s):   [SOLIS BRIDGE APPT REV]  at Flat Amount of $0.00.      Plus:    Daily Charge Grouping:  Event properties: Detail Charges with Table Code(s): [SOLIS ECT OP REV]   Do not consume all charges on matched days; only consume charges as indicated by reimbursement groups.    Reimbursement Group: UB Lines with Revenue Code(s):   [SOLIS ECT OP REV]  at Flat Amount of $0.00.      Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    100% of Standard Medicare OPPS (APC and Fee Schedule) pricing, per CMS,    revised quarterly.     Use this provider number in place of provider number from claim: 100034     Replace blank service dates with Service To date     Zero denied totals     Not doing APC bundling     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Number of retroactive years on weight adjustment: 0     Ignore the Device Code edit ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,351.77,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTX SEEDHDR IR 192 SOURCE,27894133,CDM,0278,RC,C1717,HCPCS,335,EAPG,,outpatient,facility,,,354.64,354.64,147.73,165.46,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.5,,,fee schedule,,,,,,,,,,,,,,,155.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,165.46,,,fee schedule,,,,,,,,,,,,,,,147.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTX YTTRIUM 90 PER SOURCE,27899900,CDM,0278,RC,C2616,HCPCS,,,,inpatient,facility,,,44987.5,44987.5,20244.38,44987.5,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,38239.38,,,percent of total billed charges,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",24743.13,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,24743.13,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35990,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,33740.62,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,24743.13,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,27194.94,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",31941.12,,,percent of total billed charges,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,31491.25,,,percent of total billed charges,,,,,,26992.5,,,percent of total billed charges,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,38239.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,24743.13,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44987.5,,,percent of total billed charges,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,33740.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,44987.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,20244.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38239.38,,,percent of total billed charges,,,,,,29241.88,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC BRACHYTX YTTRIUM 90 PER SOURCE,27899900,CDM,0278,RC,C2616,HCPCS,,,,outpatient,facility,,,44987.5,44987.5,129.72,44987.5,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,38239.38,,,percent of total billed charges,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30366.57,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,33740.62,,,percent of total billed charges,,,,,,31491.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29241.88,,,percent of total billed charges,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,30366.57,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,44987.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,31491.25,,,percent of total billed charges,,,,,,,,,,,,,,,44987.5,,,percent of total billed charges,,,,,,31378.78,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,31941.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,31491.25,,,percent of total billed charges,,,,,,26992.5,,,percent of total billed charges,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,38239.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44987.5,,,percent of total billed charges,,,,,,44987.5,,,percent of total billed charges,,,,,,24743.13,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,44987.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,44987.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33740.62,,,percent of total billed charges,,,,,,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,44987.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,44987.5,,,percent of total billed charges,,,,,,20244.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33740.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17771.01,,,fee schedule,,,,,,44987.5,,,percent of total billed charges,,,,,,44987.5,,,percent of total billed charges,,,,,,44987.5,,,percent of total billed charges,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,44987.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,38239.38,,,percent of total billed charges,,,,,,33740.63,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BRACHYTX YTTRIUM 90 PER SOURCE,27899900,CDM,0278,RC,C2616,HCPCS,02616,APC,,outpatient,facility,,,44987.5,44987.5,15105.36,40984.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18481.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,22213.76,,,fee schedule,,,,,,40984.39,,,fee schedule,,,,,,24743.13,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",24743.13,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",24743.13,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",24743.13,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,17771.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17771.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15105.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21325.21,,,fee schedule,,,,,,18126.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,17771.01,,,fee schedule,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,26656.52,,,fee schedule,,,,,,17771.01,,,fee schedule,,,,,,24743.13,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,17771.01,,,fee schedule,,,,,,24743.13,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,19014.98,,,fee schedule,,,,,,18729.76,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17450.31,,,fee schedule,,,,,,17771.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,17450.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22213.76,,,fee schedule,,,,,,,,,,,,,,,22213.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,24743.13,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,24743.13,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18659.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17450.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTX YTTRIUM 90 PER SOURCE,27899900,CDM,0278,RC,C2616,HCPCS,337,EAPG,,outpatient,facility,,,44987.5,44987.5,7328.58,8208.01,,,,,,,,,,,7328.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7328.58,,,fee schedule,,,,,,,,,,,,,,,7328.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8061.44,,,fee schedule,,,,,,,,,,,,,,,7695.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,8208.01,,,fee schedule,,,,,,,,,,,,,,,7328.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTX YTTRIUM 90 PER SOURCE BOSTON SCI,27899901,CDM,0278,RC,C2616,HCPCS,,,,inpatient,facility,,,43494.1,43494.1,19572.35,43494.1,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,36969.98,,,percent of total billed charges,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",23921.76,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,23921.76,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34795.28,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,32620.57,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,23921.76,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,26292.18,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",30880.81,,,percent of total billed charges,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,30445.87,,,percent of total billed charges,,,,,,26096.46,,,percent of total billed charges,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,36969.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,23921.76,23921.76,23921.76,1 through 10,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services,,,,,,,,,,23921.76,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43494.1,,,percent of total billed charges,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,32620.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,43494.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,19572.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36969.98,,,percent of total billed charges,,,,,,28271.17,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
HC BRACHYTX YTTRIUM 90 PER SOURCE BOSTON SCI,27899901,CDM,0278,RC,C2616,HCPCS,,,,outpatient,facility,,,43494.1,43494.1,129.72,43494.1,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,36969.98,,,percent of total billed charges,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,29358.51,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * .90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,32620.58,,,percent of total billed charges,,,,,,30445.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28271.17,,,percent of total billed charges,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,29358.51,,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ",other,,,,0,"MEDICAL/SURGICAL Procedures:   Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):   [FL WC APPENDIX B OP SERVICES]: (111.60% of base rate in table)   No Mod 50   Apply the following multipliers to the calculated amount from above for    1st procedure and all subsequent procedures payable at 100%.   If not found in fee schedule OR fee schedule amount is zero, then use default  reimbursement percentage of 75.00% Formula:= ( Current Amount * 0.90 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,43494.1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,30445.87,,,percent of total billed charges,,,,,,,,,,,,,,,43494.1,,,percent of total billed charges,,,,,,30337.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,30880.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,30445.87,,,percent of total billed charges,,,,,,26096.46,,,percent of total billed charges,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,36969.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43494.1,,,percent of total billed charges,,,,,,43494.1,,,percent of total billed charges,,,,,,23921.76,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,43494.1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,43494.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32620.57,,,percent of total billed charges,,,,,,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,43494.1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,43494.1,,,percent of total billed charges,,,,,,19572.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32620.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17771.01,,,fee schedule,,,,,,43494.1,,,percent of total billed charges,,,,,,43494.1,,,percent of total billed charges,,,,,,43494.1,,,percent of total billed charges,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,43494.1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,36969.98,,,percent of total billed charges,,,,,,32620.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
HC BRACHYTX YTTRIUM 90 PER SOURCE BOSTON SCI,27899901,CDM,0278,RC,C2616,HCPCS,02616,APC,,outpatient,facility,,,43494.1,43494.1,15105.36,40984.39,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18481.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,22213.76,,,fee schedule,,,,,,40984.39,,,fee schedule,,,,,,23921.76,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",23921.76,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",23921.76,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",23921.76,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%.",,,,,,,,,,17771.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,17771.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15105.36,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,21325.21,,,fee schedule,,,,,,18126.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,17771.01,,,fee schedule,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,26656.52,,,fee schedule,,,,,,17771.01,,,fee schedule,,,,,,23921.76,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,23921.76,23921.76,23921.76,1 through 10,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services,17771.01,,,fee schedule,,,,,,23921.76,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,,,,,,,,,,19014.98,,,fee schedule,,,,,,18729.76,,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ",other,,,,0,"Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 107% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit   Home Health Pricing (on or after Jan. 1, 2020)  Apply Non-timely submission reduction Formula:= ( Current Amount * 0.9850 ) ; Zero instances of the item or service in the 15 months prior to posting the file.",23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17450.31,,,fee schedule,,,,,,17771.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,17450.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22213.76,,,fee schedule,,,,,,,,,,,,,,,22213.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,23921.76,,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 5000.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,23921.76,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18659.56,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17450.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
HC BRACHYTX YTTRIUM 90 PER SOURCE BOSTON SCI,27899901,CDM,0278,RC,C2616,HCPCS,337,EAPG,,outpatient,facility,,,43494.1,43494.1,7328.58,8208.01,,,,,,,,,,,7328.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7328.58,,,fee schedule,,,,,,,,,,,,,,,7328.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8061.44,,,fee schedule,,,,,,,,,,,,,,,7695.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,8208.01,,,fee schedule,,,,,,,,,,,,,,,7328.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
DEX 5percent INJ MULTIPK 50ML 2B0088,279,CDM,0258,RC,,,,,,inpatient,facility,,,76.45,76.45,34.4,76.45,,,,,,,,,,,,,,,,,,,,64.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,53.52,,,percent of total billed charges,,,,,,45.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,64.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,76.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,34.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.98,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent INJ MULTIPK 50ML 2B0088,279,CDM,0258,RC,,,,,,outpatient,facility,,,76.45,76.45,14.53,1016,,49.69,,,percent of total billed charges,,,,,,,,,,,,,,,64.98,,,percent of total billed charges,,,,,,22.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,35.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,14.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,14.53,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,57.33,,,percent of total billed charges,,,,,,53.52,,,percent of total billed charges,,,,,,53.52,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,49.69,,,percent of total billed charges,,,,,,18.35,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,76.45,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,32.11,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",53.52,,,percent of total billed charges,,,,,,,,,,,,,,,76.45,,,percent of total billed charges,,,,,,53.32,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,54.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,53.52,,,percent of total billed charges,,,,,,45.87,,,percent of total billed charges,,,,,,34.4,,,percent of total billed charges,,,,,,,,,,,,,,,64.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.45,,,percent of total billed charges,,,,,,76.45,,,percent of total billed charges,,,,,,32.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,76.45,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,76.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.34,,,percent of total billed charges,,,,,,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,76.45,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,76.45,,,percent of total billed charges,,,,,,34.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.45,,,fee schedule,,,,,,76.45,,,percent of total billed charges,,,,,,76.45,,,percent of total billed charges,,,,,,76.45,,,percent of total billed charges,,,,,,36.7,,,percent of total billed charges,,,,,,,,,,,,,,,45.11,,,percent of total billed charges,,,,,,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,76.45,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,64.98,,,percent of total billed charges,,,,,,57.34,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 30,27902,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 30,27902,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 40,27904,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 40,27904,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 45,27905,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 45,27905,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 50,27906,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 50,27906,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 55,27907,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 55,27907,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 60,27908,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 60,27908,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 65,27909,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 65,27909,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 70,27910,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 70,27910,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 75,27911,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 75,27911,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 80,27912,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 80,27912,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 85,27913,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 85,27913,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 90,27914,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 90,27914,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 95,27915,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 95,27915,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 100,27916,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 100,27916,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 105,27917,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 105,27917,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 110,27918,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 110,27918,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 115,27919,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 115,27919,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 120,27920,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 120,27920,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 125,27921,CDM,0278,RC,,,,,,inpatient,facility,,,1245.5,1245.5,560.48,1245.5,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1058.68,,,percent of total billed charges,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,996.4,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,934.12,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,685.03,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,752.9,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",884.3,,,percent of total billed charges,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,871.85,,,percent of total billed charges,,,,,,747.3,,,percent of total billed charges,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1058.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.03,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1245.5,,,percent of total billed charges,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,934.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1245.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,560.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.68,,,percent of total billed charges,,,,,,809.58,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 125,27921,CDM,0278,RC,,,,,,outpatient,facility,,,1245.5,1245.5,129.72,1245.5,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1058.68,,,percent of total billed charges,,,,,,373.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,236.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,236.65,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,934.12,,,percent of total billed charges,,,,,,871.85,,,percent of total billed charges,,,,,,871.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,809.58,,,percent of total billed charges,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,1245.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,871.85,,,percent of total billed charges,,,,,,685.03,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1245.5,,,percent of total billed charges,,,,,,868.74,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,884.3,,,percent of total billed charges,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,871.85,,,percent of total billed charges,,,,,,747.3,,,percent of total billed charges,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1058.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,685.03,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,1245.5,,,percent of total billed charges,,,,,,1245.5,,,percent of total billed charges,,,,,,685.03,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,1245.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1245.5,,,percent of total billed charges,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,934.12,,,percent of total billed charges,,,,,,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1245.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1245.5,,,percent of total billed charges,,,,,,560.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,934.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1245.5,,,fee schedule,,,,,,1245.5,,,percent of total billed charges,,,,,,1245.5,,,percent of total billed charges,,,,,,1245.5,,,percent of total billed charges,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,685.03,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1245.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1058.68,,,percent of total billed charges,,,,,,934.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI FULL TH 7.0 X 130,27922,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI FULL TH 7.0 X 130,27922,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 30,27923,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 30,27923,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 35,27924,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 35,27924,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 40,27925,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 40,27925,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 45,27926,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 45,27926,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 50,27927,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 50,27927,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 55,27928,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 55,27928,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 60,27929,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 60,27929,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 65,27930,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 65,27930,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 70,27931,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 70,27931,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 75,27932,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 75,27932,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 80,27933,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 80,27933,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 85,27934,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 85,27934,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 90,27935,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 90,27935,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 95,27936,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 95,27936,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 100,27937,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 100,27937,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 105,27938,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 105,27938,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 110,27939,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 110,27939,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 115,27940,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 115,27940,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 120,27941,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 120,27941,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 125,27942,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 125,27942,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 130,27943,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 130,27943,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 135,27944,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 135,27944,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 140,27945,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 140,27945,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 145,27946,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 145,27946,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 16 TH 7.0 X 150,27947,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 16 TH 7.0 X 150,27947,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 45,27948,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 45,27948,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 50,27949,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 50,27949,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 55,27950,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 55,27950,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 60,27951,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 60,27951,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 70,27953,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 70,27953,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 75,27954,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 75,27954,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 80,27955,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 80,27955,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 85,27956,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 85,27956,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 90,27957,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 90,27957,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 95,27958,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 95,27958,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 100,27959,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 100,27959,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 105,27960,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 105,27960,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 110,27961,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 110,27961,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 115,27962,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 115,27962,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 120,27963,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 120,27963,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 125,27964,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 125,27964,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 130,27965,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 130,27965,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 135,27966,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 135,27966,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 140,27967,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 140,27967,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 145,27968,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 145,27968,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN TI 32 TH 7.0 X 150,27969,CDM,0278,RC,,,,,,inpatient,facility,,,256.5,256.5,115.42,256.5,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.2,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,192.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,155.05,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,166.72,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN TI 32 TH 7.0 X 150,27969,CDM,0278,RC,,,,,,outpatient,facility,,,256.5,256.5,48.73,256.5,,166.72,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,76.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,120.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,48.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,141.08,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,192.38,,,percent of total billed charges,,,,,,179.55,,,percent of total billed charges,,,,,,179.55,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,166.72,,,percent of total billed charges,,,,,,61.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,256.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,107.73,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",179.55,,,percent of total billed charges,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,178.91,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,182.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,179.55,,,percent of total billed charges,,,,,,153.9,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,218.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,110.3,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,256.5,,,percent of total billed charges,,,,,,115.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,,fee schedule,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,256.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,256.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,218.02,,,percent of total billed charges,,,,,,192.38,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 30,27970,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 30,27970,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 35,27971,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 35,27971,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 40,27972,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 40,27972,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 45,27973,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 45,27973,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 50,27974,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 50,27974,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 55,27975,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 55,27975,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 60,27976,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 60,27976,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 65,27977,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 65,27977,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 70,27978,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 70,27978,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 75,27979,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 75,27979,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 80,27980,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 80,27980,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 85,27981,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 85,27981,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 90,27982,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 90,27982,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 95,27983,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 95,27983,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 100,27984,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 100,27984,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 105,27985,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 105,27985,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 110,27986,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 110,27986,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 115,27987,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 115,27987,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 120,27988,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 120,27988,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 125,27989,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 125,27989,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS FULL TH 7.0 X 130,27990,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS FULL TH 7.0 X 130,27990,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 30,27991,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 30,27991,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 35,27992,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 35,27992,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 40,27993,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 40,27993,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 45,27994,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 45,27994,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 50,27995,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 50,27995,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 55,27996,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 55,27996,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 60,27997,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 60,27997,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 65,27998,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 65,27998,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 70,27999,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 70,27999,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX 5percent INJ MULTIPK 100M 2B0089,280,CDM,0258,RC,,,,,,inpatient,facility,,,4.77,4.77,2.15,4.77,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,,,,2.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent INJ MULTIPK 100M 2B0089,280,CDM,0258,RC,,,,,,outpatient,facility,,,4.77,4.77,0.91,1016,,3.1,,,percent of total billed charges,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,1.43,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.91,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,3.58,,,percent of total billed charges,,,,,,3.34,,,percent of total billed charges,,,,,,3.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,3.1,,,percent of total billed charges,,,,,,1.14,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,4.77,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",3.34,,,percent of total billed charges,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,3.33,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,3.34,,,percent of total billed charges,,,,,,2.86,,,percent of total billed charges,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,4.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,4.77,,,percent of total billed charges,,,,,,2.05,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.77,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4.77,,,percent of total billed charges,,,,,,2.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.77,,,fee schedule,,,,,,4.77,,,percent of total billed charges,,,,,,4.77,,,percent of total billed charges,,,,,,4.77,,,percent of total billed charges,,,,,,2.29,,,percent of total billed charges,,,,,,,,,,,,,,,2.81,,,percent of total billed charges,,,,,,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4.77,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4.05,,,percent of total billed charges,,,,,,3.58,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 75,28000,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 75,28000,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 80,28001,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 80,28001,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 85,28002,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 85,28002,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 90,28003,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 90,28003,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 95,28004,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 95,28004,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 100,28005,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 100,28005,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 105,28006,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 105,28006,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 110,28007,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 110,28007,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 115,28008,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 115,28008,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 120,28009,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 120,28009,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 125,28010,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 125,28010,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 130,28011,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 130,28011,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 135,28012,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 135,28012,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 140,28013,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 140,28013,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 145,28014,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 145,28014,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 16 TH 7.0 X 150,28015,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 16 TH 7.0 X 150,28015,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 45,28016,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 45,28016,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 50,28017,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 50,28017,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 55,28018,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 55,28018,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 60,28019,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 60,28019,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 65,28020,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 65,28020,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 70,28021,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 70,28021,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 75,28022,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 75,28022,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 80,28023,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 80,28023,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 85,28024,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 85,28024,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 90,28025,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 90,28025,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 95,28026,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 95,28026,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 100,28027,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 100,28027,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 105,28028,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 105,28028,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 110,28029,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 110,28029,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 115,28030,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 115,28030,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 120,28031,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 120,28031,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 125,28032,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 125,28032,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 130,28033,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 130,28033,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 135,28034,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 135,28034,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 140,28035,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 140,28035,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 145,28036,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 145,28036,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SMI CANN SS 32 TH 7.0 X 150,28037,CDM,0278,RC,,,,,,inpatient,facility,,,247,247,111.15,247,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.6,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,185.25,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.31,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,160.55,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SMI CANN SS 32 TH 7.0 X 150,28037,CDM,0278,RC,,,,,,outpatient,facility,,,247,247,46.93,247,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,74.1,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,116.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,46.93,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,135.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,185.25,,,percent of total billed charges,,,,,,172.9,,,percent of total billed charges,,,,,,172.9,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,160.55,,,percent of total billed charges,,,,,,59.28,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,247,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,103.74,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",172.9,,,percent of total billed charges,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,172.28,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,175.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,172.9,,,percent of total billed charges,,,,,,148.2,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,106.21,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,247,,,percent of total billed charges,,,,,,111.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,,fee schedule,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,247,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,209.95,,,percent of total billed charges,,,,,,185.25,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
NAIL SYN FEM DISTAL TI STRL 13 X 300,28049,CDM,0278,RC,,,,,,inpatient,facility,,,3484.22,3484.22,1567.9,3484.22,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2961.59,,,percent of total billed charges,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2787.38,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2613.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1916.32,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2106.21,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",2473.8,,,percent of total billed charges,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2438.95,,,percent of total billed charges,,,,,,2090.53,,,percent of total billed charges,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2961.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1916.32,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.22,,,percent of total billed charges,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,2613.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,3484.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1567.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2961.59,,,percent of total billed charges,,,,,,2264.74,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
NAIL SYN FEM DISTAL TI STRL 13 X 300,28049,CDM,0278,RC,,,,,,outpatient,facility,,,3484.22,3484.22,129.72,3484.22,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2961.59,,,percent of total billed charges,,,,,,1045.27,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,662,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,662,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2613.17,,,percent of total billed charges,,,,,,2438.95,,,percent of total billed charges,,,,,,2438.95,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2264.74,,,percent of total billed charges,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,3484.22,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2438.95,,,percent of total billed charges,,,,,,1916.32,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3484.22,,,percent of total billed charges,,,,,,2430.24,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,2473.8,,,percent of total billed charges,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2438.95,,,percent of total billed charges,,,,,,2090.53,,,percent of total billed charges,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2961.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1916.32,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,3484.22,,,percent of total billed charges,,,,,,3484.22,,,percent of total billed charges,,,,,,1916.32,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.22,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,3484.22,,,percent of total billed charges,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,2613.16,,,percent of total billed charges,,,,,,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,3484.22,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,3484.22,,,percent of total billed charges,,,,,,1567.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2613.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3484.22,,,fee schedule,,,,,,3484.22,,,percent of total billed charges,,,,,,3484.22,,,percent of total billed charges,,,,,,3484.22,,,percent of total billed charges,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,1916.32,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,3484.22,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,2961.59,,,percent of total billed charges,,,,,,2613.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
END CAP SYN TI FEM NAIL,28051,CDM,0278,RC,,,,,,inpatient,facility,,,382.8,382.8,172.26,382.8,,,,,,,,,,,,,,,,,,,,325.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306.24,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,287.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.4,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",271.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,267.96,,,percent of total billed charges,,,,,,229.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,325.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,382.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,172.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.38,,,percent of total billed charges,,,,,,248.82,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
END CAP SYN TI FEM NAIL,28051,CDM,0278,RC,,,,,,outpatient,facility,,,382.8,382.8,72.73,382.8,,248.82,,,percent of total billed charges,,,,,,,,,,,,,,,325.38,,,percent of total billed charges,,,,,,114.84,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,179.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,72.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,72.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,210.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,210.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,210.54,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,287.1,,,percent of total billed charges,,,,,,267.96,,,percent of total billed charges,,,,,,267.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,248.82,,,percent of total billed charges,,,,,,91.87,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,382.8,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,160.78,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",267.96,,,percent of total billed charges,,,,,,,,,,,,,,,382.8,,,percent of total billed charges,,,,,,267,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,271.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,267.96,,,percent of total billed charges,,,,,,229.68,,,percent of total billed charges,,,,,,172.26,,,percent of total billed charges,,,,,,,,,,,,,,,325.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.8,,,percent of total billed charges,,,,,,382.8,,,percent of total billed charges,,,,,,164.6,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,382.8,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,382.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.1,,,percent of total billed charges,,,,,,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,382.8,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,382.8,,,percent of total billed charges,,,,,,172.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.8,,,fee schedule,,,,,,382.8,,,percent of total billed charges,,,,,,382.8,,,percent of total billed charges,,,,,,382.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,382.8,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,325.38,,,percent of total billed charges,,,,,,287.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT SYN CANN 13.0 X 300,28052,CDM,0272,RC,,,,,,inpatient,facility,,,1884.26,1884.26,847.92,1884.26,,,,,,,,,,,,,,,,,,,,1601.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1224.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1337.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1318.98,,,percent of total billed charges,,,,,,1130.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1601.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1884.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1884.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,847.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1601.62,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT SYN CANN 13.0 X 300,28052,CDM,0272,RC,,,,,,outpatient,facility,,,1884.26,1884.26,129.72,1884.26,,1224.77,,,percent of total billed charges,,,,,,,,,,,,,,,1601.62,,,percent of total billed charges,,,,,,565.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,885.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,358.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,358.01,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,1413.2,,,percent of total billed charges,,,,,,1318.98,,,percent of total billed charges,,,,,,1318.98,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,1224.77,,,percent of total billed charges,,,,,,452.22,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1271.88,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1884.26,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,791.39,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",1318.98,,,percent of total billed charges,,,,,,,,,,,,,,,1884.26,,,percent of total billed charges,,,,,,1314.27,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,1337.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,1318.98,,,percent of total billed charges,,,,,,1130.56,,,percent of total billed charges,,,,,,847.92,,,percent of total billed charges,,,,,,,,,,,,,,,1601.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1884.26,,,percent of total billed charges,,,,,,1884.26,,,percent of total billed charges,,,,,,810.23,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1884.26,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1884.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.2,,,percent of total billed charges,,,,,,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1884.26,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1884.26,,,percent of total billed charges,,,,,,847.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1884.26,,,fee schedule,,,,,,1884.26,,,percent of total billed charges,,,,,,1884.26,,,percent of total billed charges,,,,,,1884.26,,,percent of total billed charges,,,,,,904.44,,,percent of total billed charges,,,,,,,,,,,,,,,1111.71,,,percent of total billed charges,,,,,,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1884.26,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1601.62,,,percent of total billed charges,,,,,,1413.19,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN LOCK MINI TI 6.0 X 70,28053,CDM,0278,RC,,,,,,inpatient,facility,,,386.76,386.76,174.04,386.76,,,,,,,,,,,,,,,,,,,,328.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,309.41,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,290.07,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.8,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",274.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,270.73,,,percent of total billed charges,,,,,,232.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,328.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,386.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,174.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.75,,,percent of total billed charges,,,,,,251.39,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN LOCK MINI TI 6.0 X 70,28053,CDM,0278,RC,,,,,,outpatient,facility,,,386.76,386.76,73.48,386.76,,251.39,,,percent of total billed charges,,,,,,,,,,,,,,,328.75,,,percent of total billed charges,,,,,,116.03,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,181.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,212.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,73.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,73.48,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,212.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,212.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,212.72,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,290.07,,,percent of total billed charges,,,,,,270.73,,,percent of total billed charges,,,,,,270.73,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,251.39,,,percent of total billed charges,,,,,,92.82,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,386.76,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,162.44,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",270.73,,,percent of total billed charges,,,,,,,,,,,,,,,386.76,,,percent of total billed charges,,,,,,269.77,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,274.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,270.73,,,percent of total billed charges,,,,,,232.06,,,percent of total billed charges,,,,,,174.04,,,percent of total billed charges,,,,,,,,,,,,,,,328.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.76,,,percent of total billed charges,,,,,,386.76,,,percent of total billed charges,,,,,,166.31,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,386.76,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,386.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.07,,,percent of total billed charges,,,,,,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,386.76,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,386.76,,,percent of total billed charges,,,,,,174.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,290.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.76,,,fee schedule,,,,,,386.76,,,percent of total billed charges,,,,,,386.76,,,percent of total billed charges,,,,,,386.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,386.76,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,328.75,,,percent of total billed charges,,,,,,290.07,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN LAG DHS DCS 1 STEP SS TH 12.7 X 90,28055,CDM,0278,RC,,,,,,inpatient,facility,,,656.18,656.18,295.28,656.18,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,492.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",465.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,459.33,,,percent of total billed charges,,,,,,393.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,360.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,426.52,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN LAG DHS DCS 1 STEP SS TH 12.7 X 90,28055,CDM,0278,RC,,,,,,outpatient,facility,,,656.18,656.18,124.67,656.18,,426.52,,,percent of total billed charges,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,196.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,308.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,124.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,492.13,,,percent of total billed charges,,,,,,459.33,,,percent of total billed charges,,,,,,459.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,426.52,,,percent of total billed charges,,,,,,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,656.18,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,275.6,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",459.33,,,percent of total billed charges,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,457.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,465.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,459.33,,,percent of total billed charges,,,,,,393.71,,,percent of total billed charges,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,360.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,,percent of total billed charges,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,,percent of total billed charges,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,fee schedule,,,,,,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,557.75,,,percent of total billed charges,,,,,,492.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN LAG DHS DCS 1 STEP SS TH 12.7 X 100,28111,CDM,0278,RC,,,,,,inpatient,facility,,,656.18,656.18,295.28,656.18,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,492.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",465.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,459.33,,,percent of total billed charges,,,,,,393.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,360.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,426.52,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN LAG DHS DCS 1 STEP SS TH 12.7 X 100,28111,CDM,0278,RC,,,,,,outpatient,facility,,,656.18,656.18,124.67,656.18,,426.52,,,percent of total billed charges,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,196.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,308.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,124.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,492.13,,,percent of total billed charges,,,,,,459.33,,,percent of total billed charges,,,,,,459.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,426.52,,,percent of total billed charges,,,,,,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,656.18,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,275.6,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",459.33,,,percent of total billed charges,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,457.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,465.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,459.33,,,percent of total billed charges,,,,,,393.71,,,percent of total billed charges,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,360.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,,percent of total billed charges,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,,percent of total billed charges,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,fee schedule,,,,,,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,557.75,,,percent of total billed charges,,,,,,492.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
OCCLUDER VASCU VESSEL DISP 1.50ML  i,28282,CDM,0272,RC,,,,,,inpatient,facility,,,320.47,320.47,144.21,320.47,,,,,,,,,,,,,,,,,,,,272.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.33,,,percent of total billed charges,,,,,,192.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,272.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,320.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,144.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.4,,,percent of total billed charges,,,,,,,,,,,,,,
OCCLUDER VASCU VESSEL DISP 1.50ML  i,28282,CDM,0272,RC,,,,,,outpatient,facility,,,320.47,320.47,60.89,1016,,208.31,,,percent of total billed charges,,,,,,,,,,,,,,,272.4,,,percent of total billed charges,,,,,,96.14,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,150.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,60.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,60.89,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,240.36,,,percent of total billed charges,,,,,,224.33,,,percent of total billed charges,,,,,,224.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,208.31,,,percent of total billed charges,,,,,,76.91,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",216.32,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,320.47,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,134.6,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",224.33,,,percent of total billed charges,,,,,,,,,,,,,,,320.47,,,percent of total billed charges,,,,,,223.53,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,227.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,224.33,,,percent of total billed charges,,,,,,192.28,,,percent of total billed charges,,,,,,144.21,,,percent of total billed charges,,,,,,,,,,,,,,,272.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.47,,,percent of total billed charges,,,,,,320.47,,,percent of total billed charges,,,,,,137.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,320.47,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,320.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.35,,,percent of total billed charges,,,,,,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,320.47,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,320.47,,,percent of total billed charges,,,,,,144.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,320.47,,,fee schedule,,,,,,320.47,,,percent of total billed charges,,,,,,320.47,,,percent of total billed charges,,,,,,320.47,,,percent of total billed charges,,,,,,153.83,,,percent of total billed charges,,,,,,,,,,,,,,,189.08,,,percent of total billed charges,,,,,,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,320.47,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,272.4,,,percent of total billed charges,,,,,,240.35,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX 5percent AND .45percent NACL 1000ML 2B1074X  i,283,CDM,0258,RC,,,,,,inpatient,facility,,,6.2,6.2,2.79,6.2,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.34,,,percent of total billed charges,,,,,,3.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent AND .45percent NACL 1000ML 2B1074X  i,283,CDM,0258,RC,,,,,,outpatient,facility,,,6.2,6.2,1.18,1016,,4.03,,,percent of total billed charges,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,1.86,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.18,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.66,,,percent of total billed charges,,,,,,4.34,,,percent of total billed charges,,,,,,4.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4.03,,,percent of total billed charges,,,,,,1.49,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,6.2,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.6,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.34,,,percent of total billed charges,,,,,,,,,,,,,,,6.2,,,percent of total billed charges,,,,,,4.32,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,4.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.34,,,percent of total billed charges,,,,,,3.72,,,percent of total billed charges,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,5.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,percent of total billed charges,,,,,,6.2,,,percent of total billed charges,,,,,,2.67,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,6.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.2,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.2,,,percent of total billed charges,,,,,,2.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.2,,,fee schedule,,,,,,6.2,,,percent of total billed charges,,,,,,6.2,,,percent of total billed charges,,,,,,6.2,,,percent of total billed charges,,,,,,2.98,,,percent of total billed charges,,,,,,,,,,,,,,,3.66,,,percent of total billed charges,,,,,,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6.2,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.27,,,percent of total billed charges,,,,,,4.65,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
RESTRICTOR DEP CEMENT FEM SZ1,28357,CDM,0278,RC,,,,,,inpatient,facility,,,120.4,120.4,54.18,120.4,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.32,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,90.3,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.78,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",85.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.28,,,percent of total billed charges,,,,,,72.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,78.26,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
RESTRICTOR DEP CEMENT FEM SZ1,28357,CDM,0278,RC,,,,,,outpatient,facility,,,120.4,120.4,22.88,138.8,,78.26,,,percent of total billed charges,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,36.12,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,56.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,22.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,22.88,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,66.22,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,90.3,,,percent of total billed charges,,,,,,84.28,,,percent of total billed charges,,,,,,84.28,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,78.26,,,percent of total billed charges,,,,,,28.9,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,120.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,50.57,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",84.28,,,percent of total billed charges,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,83.98,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,85.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,84.28,,,percent of total billed charges,,,,,,72.24,,,percent of total billed charges,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,102.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,51.77,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,120.4,,,percent of total billed charges,,,,,,54.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,,fee schedule,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,120.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,120.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,102.34,,,percent of total billed charges,,,,,,90.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PLATE ZIM FL COMP SCP 130DG 2H 59MM,28359,CDM,0278,RC,,,,,,inpatient,facility,,,894.4,894.4,402.48,894.4,,,,,,,,,,,,,,,,,,,,760.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,715.52,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,670.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,491.92,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,540.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",635.02,,,percent of total billed charges,,,,,,,,,,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,626.08,,,percent of total billed charges,,,,,,536.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,760.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.92,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,491.92,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.4,,,percent of total billed charges,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,670.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,894.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,402.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,760.24,,,percent of total billed charges,,,,,,581.36,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PLATE ZIM FL COMP SCP 130DG 2H 59MM,28359,CDM,0278,RC,,,,,,outpatient,facility,,,894.4,894.4,129.72,894.4,,581.36,,,percent of total billed charges,,,,,,,,,,,,,,,760.24,,,percent of total billed charges,,,,,,268.32,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,420.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,169.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,670.8,,,percent of total billed charges,,,,,,626.08,,,percent of total billed charges,,,,,,626.08,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,581.36,,,percent of total billed charges,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,894.4,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,626.08,,,percent of total billed charges,,,,,,491.92,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,894.4,,,percent of total billed charges,,,,,,623.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,635.02,,,percent of total billed charges,,,,,,,,,,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,626.08,,,percent of total billed charges,,,,,,536.64,,,percent of total billed charges,,,,,,402.48,,,percent of total billed charges,,,,,,,,,,,,,,,760.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,491.92,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,894.4,,,percent of total billed charges,,,,,,894.4,,,percent of total billed charges,,,,,,491.92,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,894.4,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,894.4,,,percent of total billed charges,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,670.8,,,percent of total billed charges,,,,,,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,894.4,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,894.4,,,percent of total billed charges,,,,,,402.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,670.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,491.92,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,894.4,,,fee schedule,,,,,,894.4,,,percent of total billed charges,,,,,,894.4,,,percent of total billed charges,,,,,,894.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,894.4,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,760.24,,,percent of total billed charges,,,,,,670.8,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 95,28379,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 95,28379,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 115,28383,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 115,28383,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 120,28384,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 120,28384,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 125,28385,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 125,28385,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 130,28386,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 130,28386,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 135,28387,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 135,28387,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 140,28388,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 140,28388,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 145,28389,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 145,28389,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN SS TH 7.3 X 16 X 150,28390,CDM,0278,RC,,,,,,inpatient,facility,,,398.88,398.88,179.5,398.88,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.1,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,299.16,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,259.27,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN SS TH 7.3 X 16 X 150,28390,CDM,0278,RC,,,,,,outpatient,facility,,,398.88,398.88,75.79,398.88,,259.27,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,119.66,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,187.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,75.79,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,219.38,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,299.16,,,percent of total billed charges,,,,,,279.22,,,percent of total billed charges,,,,,,279.22,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,259.27,,,percent of total billed charges,,,,,,95.73,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,398.88,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,167.53,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",279.22,,,percent of total billed charges,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,278.22,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,283.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,279.22,,,percent of total billed charges,,,,,,239.33,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,339.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,171.52,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,398.88,,,percent of total billed charges,,,,,,179.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,,fee schedule,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,398.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,398.88,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,339.05,,,percent of total billed charges,,,,,,299.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
WASHER SYN TI 13MM,28391,CDM,0278,RC,,,,,,inpatient,facility,,,52.46,52.46,23.61,52.46,,,,,,,,,,,,,,,,,,,,44.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.97,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,39.34,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.71,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",37.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,36.72,,,percent of total billed charges,,,,,,31.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,44.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,52.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,23.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.59,,,percent of total billed charges,,,,,,34.1,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
WASHER SYN TI 13MM,28391,CDM,0278,RC,,,,,,outpatient,facility,,,52.46,52.46,9.97,138.8,,34.1,,,percent of total billed charges,,,,,,,,,,,,,,,44.59,,,percent of total billed charges,,,,,,15.74,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,24.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,9.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,9.97,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,28.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,28.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,28.85,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,39.34,,,percent of total billed charges,,,,,,36.72,,,percent of total billed charges,,,,,,36.72,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,34.1,,,percent of total billed charges,,,,,,12.59,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,52.46,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,22.03,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",36.72,,,percent of total billed charges,,,,,,,,,,,,,,,52.46,,,percent of total billed charges,,,,,,36.59,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,37.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,36.72,,,percent of total billed charges,,,,,,31.48,,,percent of total billed charges,,,,,,23.61,,,percent of total billed charges,,,,,,,,,,,,,,,44.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.46,,,percent of total billed charges,,,,,,52.46,,,percent of total billed charges,,,,,,22.56,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,52.46,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,52.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.34,,,percent of total billed charges,,,,,,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,52.46,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,52.46,,,percent of total billed charges,,,,,,23.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.46,,,fee schedule,,,,,,52.46,,,percent of total billed charges,,,,,,52.46,,,percent of total billed charges,,,,,,52.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,52.46,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,44.59,,,percent of total billed charges,,,,,,39.34,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 50,28392,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 50,28392,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 55,28393,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 55,28393,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 60,28394,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 60,28394,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 65,28395,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 65,28395,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 70,28396,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 70,28396,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 75,28397,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 75,28397,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 80,28398,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 80,28398,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 85,28399,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 85,28399,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 90,28400,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 90,28400,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 95,28401,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 95,28401,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 100,28402,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 100,28402,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 105,28403,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 105,28403,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 110,28404,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 110,28404,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 115,28405,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 115,28405,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 120,28406,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 120,28406,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 125,28407,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 125,28407,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN CANN MINI TI TH 7.3 X 32 X 130,28408,CDM,0278,RC,,,,,,inpatient,facility,,,438.48,438.48,197.32,438.48,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350.78,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,328.86,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,265.06,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,285.01,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN CANN MINI TI TH 7.3 X 32 X 130,28408,CDM,0278,RC,,,,,,outpatient,facility,,,438.48,438.48,83.31,438.48,,285.01,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,131.54,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,206.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,241.16,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,328.86,,,percent of total billed charges,,,,,,306.94,,,percent of total billed charges,,,,,,306.94,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,285.01,,,percent of total billed charges,,,,,,105.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,438.48,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,184.16,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.94,,,percent of total billed charges,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,305.84,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,311.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.94,,,percent of total billed charges,,,,,,263.09,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,372.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,188.55,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,438.48,,,percent of total billed charges,,,,,,197.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,fee schedule,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,438.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,438.48,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,372.71,,,percent of total billed charges,,,,,,328.86,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
SCR SYN LAG DHS DCS 1 STEP SS TH 12.7 X 85,28422,CDM,0278,RC,,,,,,inpatient,facility,,,656.18,656.18,295.28,656.18,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.94,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,492.13,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.66,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",465.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,459.33,,,percent of total billed charges,,,,,,393.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,360.9,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,426.52,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
SCR SYN LAG DHS DCS 1 STEP SS TH 12.7 X 85,28422,CDM,0278,RC,,,,,,outpatient,facility,,,656.18,656.18,124.67,656.18,,426.52,,,percent of total billed charges,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,196.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,308.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,124.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,124.67,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,492.13,,,percent of total billed charges,,,,,,459.33,,,percent of total billed charges,,,,,,459.33,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,426.52,,,percent of total billed charges,,,,,,360.9,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,656.18,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,275.6,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",459.33,,,percent of total billed charges,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,457.69,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,465.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,459.33,,,percent of total billed charges,,,,,,393.71,,,percent of total billed charges,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,557.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360.9,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,360.9,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,,percent of total billed charges,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,656.18,,,percent of total billed charges,,,,,,295.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,,fee schedule,,,,,,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,656.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,656.18,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,557.75,,,percent of total billed charges,,,,,,492.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
OCCLUDER VASCU VESSEL DISP 2.00ML  i,28438,CDM,0272,RC,,,,,,inpatient,facility,,,296.52,296.52,133.43,296.52,,,,,,,,,,,,,,,,,,,,252.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,210.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,207.56,,,percent of total billed charges,,,,,,177.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,296.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,133.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.04,,,percent of total billed charges,,,,,,,,,,,,,,
OCCLUDER VASCU VESSEL DISP 2.00ML  i,28438,CDM,0272,RC,,,,,,outpatient,facility,,,296.52,296.52,56.34,1016,,192.74,,,percent of total billed charges,,,,,,,,,,,,,,,252.04,,,percent of total billed charges,,,,,,88.96,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,139.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,56.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,56.34,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,222.39,,,percent of total billed charges,,,,,,207.56,,,percent of total billed charges,,,,,,207.56,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,192.74,,,percent of total billed charges,,,,,,71.16,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",200.15,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,296.52,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,124.54,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",207.56,,,percent of total billed charges,,,,,,,,,,,,,,,296.52,,,percent of total billed charges,,,,,,206.82,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,210.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,207.56,,,percent of total billed charges,,,,,,177.91,,,percent of total billed charges,,,,,,133.43,,,percent of total billed charges,,,,,,,,,,,,,,,252.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.52,,,percent of total billed charges,,,,,,296.52,,,percent of total billed charges,,,,,,127.5,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,296.52,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,296.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,percent of total billed charges,,,,,,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,296.52,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,296.52,,,percent of total billed charges,,,,,,133.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.52,,,fee schedule,,,,,,296.52,,,percent of total billed charges,,,,,,296.52,,,percent of total billed charges,,,,,,296.52,,,percent of total billed charges,,,,,,142.33,,,percent of total billed charges,,,,,,,,,,,,,,,174.95,,,percent of total billed charges,,,,,,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,296.52,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,252.04,,,percent of total billed charges,,,,,,222.39,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DEX 5percent AND .9percent NACL 1000ML 2B1064X  i,285,CDM,0258,RC,,,,,,inpatient,facility,,,6.16,6.16,2.77,6.16,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,3.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,
DEX 5percent AND .9percent NACL 1000ML 2B1064X  i,285,CDM,0258,RC,,,,,,outpatient,facility,,,6.16,6.16,1.17,1016,,4,,,percent of total billed charges,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,1.85,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,1.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,1.17,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,4.62,,,percent of total billed charges,,,,,,4.31,,,percent of total billed charges,,,,,,4.31,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,4,,,percent of total billed charges,,,,,,1.48,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,6.16,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2.59,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",4.31,,,percent of total billed charges,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,4.3,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,4.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,4.31,,,percent of total billed charges,,,,,,3.7,,,percent of total billed charges,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,5.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,6.16,,,percent of total billed charges,,,,,,2.65,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,6.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.16,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,6.16,,,percent of total billed charges,,,,,,2.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.16,,,fee schedule,,,,,,6.16,,,percent of total billed charges,,,,,,6.16,,,percent of total billed charges,,,,,,6.16,,,percent of total billed charges,,,,,,2.96,,,percent of total billed charges,,,,,,,,,,,,,,,3.63,,,percent of total billed charges,,,,,,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,6.16,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,5.24,,,percent of total billed charges,,,,,,4.62,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
CABLE PACING TEMP VENTRICLE 6,28517,CDM,0272,RC,,,,,,inpatient,facility,,,437.5,437.5,196.88,437.5,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,310.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.25,,,percent of total billed charges,,,,,,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,,,,,,
CABLE PACING TEMP VENTRICLE 6,28517,CDM,0272,RC,,,,,,outpatient,facility,,,437.5,437.5,83.13,1016,,284.38,,,percent of total billed charges,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,,,,,131.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,205.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,83.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,83.13,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,488,,,case rate,,,,,,1016,,,case rate,,,,,,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,996,,,case rate,,,,,,328.12,,,percent of total billed charges,,,,,,306.25,,,percent of total billed charges,,,,,,306.25,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,284.38,,,percent of total billed charges,,,,,,105,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",295.31,,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE,other,,,,0,75.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * 0.90 End FormulaCPE Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,437.5,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,183.75,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",306.25,,,percent of total billed charges,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,305.16,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,310.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306.25,,,percent of total billed charges,,,,,,262.5,,,percent of total billed charges,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,371.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,437.5,,,percent of total billed charges,,,,,,188.13,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,437.5,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,437.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.12,,,percent of total billed charges,,,,,,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,437.5,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,437.5,,,percent of total billed charges,,,,,,196.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,328.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.5,,,fee schedule,,,,,,437.5,,,percent of total billed charges,,,,,,437.5,,,percent of total billed charges,,,,,,437.5,,,percent of total billed charges,,,,,,210,,,percent of total billed charges,,,,,,,,,,,,,,,258.13,,,percent of total billed charges,,,,,,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,437.5,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,371.88,,,percent of total billed charges,,,,,,328.13,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATCH VAS GORTEX TW 2 X 9 .04  i,2854,CDM,0278,RC,,,,,,inpatient,facility,,,470,470,211.5,470,,,,,,,,,,,,,,,,,,,,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,376,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,352.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,284.12,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",333.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,329,,,percent of total billed charges,,,,,,282,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,470,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,211.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,399.5,,,percent of total billed charges,,,,,,305.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATCH VAS GORTEX TW 2 X 9 .04  i,2854,CDM,0278,RC,,,,,,outpatient,facility,,,470,470,89.3,470,,305.5,,,percent of total billed charges,,,,,,,,,,,,,,,399.5,,,percent of total billed charges,,,,,,141,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,220.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,89.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,89.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,258.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,258.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,258.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,352.5,,,percent of total billed charges,,,,,,329,,,percent of total billed charges,,,,,,329,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,305.5,,,percent of total billed charges,,,,,,112.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,470,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,197.4,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",329,,,percent of total billed charges,,,,,,,,,,,,,,,470,,,percent of total billed charges,,,,,,327.83,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,333.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,329,,,percent of total billed charges,,,,,,282,,,percent of total billed charges,,,,,,211.5,,,percent of total billed charges,,,,,,,,,,,,,,,399.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470,,,percent of total billed charges,,,,,,470,,,percent of total billed charges,,,,,,202.1,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,470,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,470,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,,,,,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,470,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,470,,,percent of total billed charges,,,,,,211.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470,,,fee schedule,,,,,,470,,,percent of total billed charges,,,,,,470,,,percent of total billed charges,,,,,,470,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,470,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,399.5,,,percent of total billed charges,,,,,,352.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
PATELLA DEP DOME OVAL 35MM NC,28552,CDM,0278,RC,,,,,,inpatient,facility,,,1,1,0.45,1,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.8,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,0.75,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.6,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.65,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
PATELLA DEP DOME OVAL 35MM NC,28552,CDM,0278,RC,,,,,,outpatient,facility,,,1,1,0.19,138.8,,0.65,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,0.3,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.19,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.55,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,0.76,,,percent of total billed charges,,,,,,0.7,,,percent of total billed charges,,,,,,0.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,0.65,,,percent of total billed charges,,,,,,0.24,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,1,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.42,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",0.7,,,percent of total billed charges,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,0.7,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,0.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,0.7,,,percent of total billed charges,,,,,,0.6,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,0.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,0.43,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,1,,,percent of total billed charges,,,,,,0.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,,fee schedule,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,1,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,0.85,,,percent of total billed charges,,,,,,0.75,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
FEM DEP KNEE PFC SIGMA SUB RT SZ2.5,28556,CDM,0278,RC,,,,,,inpatient,facility,,,4230,4230,1903.5,4230,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,3595.5,,,percent of total billed charges,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3384,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3172.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2326.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,2557.04,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",3003.3,,,percent of total billed charges,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2961,,,percent of total billed charges,,,,,,2538,,,percent of total billed charges,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,3595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2326.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4230,,,percent of total billed charges,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,4230,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,1903.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3595.5,,,percent of total billed charges,,,,,,2749.5,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
FEM DEP KNEE PFC SIGMA SUB RT SZ2.5,28556,CDM,0278,RC,,,,,,outpatient,facility,,,4230,4230,129.72,4230,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,3595.5,,,percent of total billed charges,,,,,,1269,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,803.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,803.7,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3172.5,,,percent of total billed charges,,,,,,2961,,,percent of total billed charges,,,,,,2961,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,2749.5,,,percent of total billed charges,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services 55.00% of Billed Charges is a good faith estimate of an equivalent to cost +10%.,,,,,,,,,,,,,,,,,,,4230,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2961,,,percent of total billed charges,,,,,,2326.5,,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type ,other,,,,0,If ( Charges In Service Type > 700.00 )   Then:  55.00 % of Charges In Service Type  Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4230,,,percent of total billed charges,,,,,,2950.43,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,3003.3,,,percent of total billed charges,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2961,,,percent of total billed charges,,,,,,2538,,,percent of total billed charges,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,3595.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2326.5,,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If,other,,,,0,If: {Charges In Service Type} >= 500.00 Then:  55.00% of Charges in Service Type End If Paid in addition to outpatient services; Zero instances of the item or service in the 15 months prior to posting the file.,4230,,,percent of total billed charges,,,,,,4230,,,percent of total billed charges,,,,,,2326.5,,,percent of total billed charges,,,,,"Paid in addition to outpatient services Per agreement with payor, Hospital Charges = approximate cost of Implant Devices + 10%",,,,,,,,,,,,,,,,,,,,,,,,,,,,4230,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,4230,,,percent of total billed charges,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,4230,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,4230,,,percent of total billed charges,,,,,,1903.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3172.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,4230,,,fee schedule,,,,,,4230,,,percent of total billed charges,,,,,,4230,,,percent of total billed charges,,,,,,4230,,,percent of total billed charges,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,,,,,,,,,,2326.5,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,4230,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,3595.5,,,percent of total billed charges,,,,,,3172.5,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
ROD MED HEX END TI 5.5 X 20,28605,CDM,0278,RC,,,,,,inpatient,facility,,,360,360,162,360,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,288,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,270,,,percent of total billed charges,,,,,Paid in addition to inpatient services ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.62,,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review ",other,,,,0,"65.00% of Charges in Service Type  FormulaCPE:  {Current Amount} * .93 End FormulaCPE  Note:  ""Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed in addition to the per diem""  Processing Action: Flag for review  Paid in addition to inpatient services; Zero instances of the item or service in the 15 months prior to posting the file.",255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,234,,,percent of total billed charges,,,,,"Paid in addition to inpatient services ~Facility marks up 2x. Surgical implant reimbursement will be thirty percent over the manufacturer's acquisition invoice cost.For Disposable Instrumentation are 20% over the acquisition invoice cost. Invoice are required. Also, Implants are reimbursed ~"
ROD MED HEX END TI 5.5 X 20,28605,CDM,0278,RC,,,,,,outpatient,facility,,,360,360,68.4,360,,234,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,108,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,169.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,68.4,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This is an IP rehabilitation     contract - please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,198,,,percent of total billed charges,,,,,Paid in addition to outpatient services ,270,,,percent of total billed charges,,,,,,252,,,percent of total billed charges,,,,,,252,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 85.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Number of retroactive years on weight adjustment: 0    Consume Units    Consume Charges    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  70.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,,,,,,,,,,234,,,percent of total billed charges,,,,,,86.4,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 24.00% End FormulaCPE  Not To Exceed:  $2,000.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,360,,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ,other,,,,0,100 % of Charges In Service Type Manual Review/Entry: Flag for review : Reimbursement from this     service type is outside of this agreement. ; Zero instances of the item or service in the 15 months prior to posting the file.,151.2,,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - ({Charges In Pass-Through Section}   + {Charges In Exclusions Section}))  * 42% End FormulaCPE  Not To Exceed:  FormulaCPE:   {Days in Visit} * 2,657.00  End FormulaCPE End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",252,,,percent of total billed charges,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,251.1,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum  FormulaCPE:  {Current Amount} * .93 End FormulaCPE ; Zero instances of the item or service in the 15 months prior to posting the file.,255.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,252,,,percent of total billed charges,,,,,,216,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,154.8,,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed",other,,,,0,"FormulaCPE:  ({Charges In Service Type} - {Charges In Pass-Through Section}) * 43.00% End FormulaCPE  Not To Exceed:  $3,254.00 Flat End Not To Exceed; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,percent of total billed charges,,,,,,138.8,,,fee schedule,,,,,,,,,,,,,,,129.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No negotiated discount for     other OP services ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If",other,,,,0,"Procedure Lookup:  Procedure Code Tables:   [[MEDICARE PHYSICIAN LOC 4]] 80.00% of Table Per Unit  Multipliers: 100.00%  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: Y   Consume Units: Y   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N  If: {Current Amount} = 0.00 Then:  100.00% of Charges in Service Type  Note:   "" The contract is for OP Medical Oncology Services only. Please review claim.""   Processing Action: Flag for review End If; Zero instances of the item or service in the 15 months prior to posting the file.",,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : The contract is for OP Medical     Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : This contract is for OP     Medical Oncology services only. Please review claim. ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,service not payable,360,,,percent of total billed charges,,,,,,162,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,,fee schedule,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,360,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : No OP discounts have been     negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Review claim ; Zero instances of the item or service in the 15 months prior to posting the file.,,,,,,,,,,360,,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ,other,,,,0,100.00 % of Charges In Service Type Manual Review/Entry: Flag for review : Contract is for IP Hospice     only. No OP rates have been negotiated. ; Zero instances of the item or service in the 15 months prior to posting the file.,306,,,percent of total billed charges,,,,,,270,,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ,other,,,,0,Interim Value: FS Codes Charges  Procedure Lookup:  Procedure Code Tables:   [[ANY CODE]] $0.00 with Revenue Code Table: [[RC 762]]   [[FL WC APPENDIX B OP SERVICES]] 100.00% of Charges   [[FL WC APPENDIX B OP SERVICES RANGE]] 100.00% of Charges  Multipliers: None  Sort By: Allowed Amount  Conditions:   Process Daily: N   Do not limit reimbursement   When duplicate code found in Procedure Code Tables use: First Code Found   Consume Charges: N   Consume Units: N   Treat zero Procedure Code Table amount as not found: N   Apply Mod50: No   Additional Modifier Table: None   LSS reimbursement: N Sum:  Procedure Lookup:   Procedure Code Tables:    [[FL WC APPENDIX B OP SERVICES]] 110.20% of Table Per Unit    [[FL WC APPENDIX B OP SERVICES RANGE]] 110.20% of Table Per Unit   Multipliers: None   Sort By: Allowed Amount   Conditions:    Process Daily: N    Do not limit reimbursement    When duplicate code found in Procedure Code Tables use: First Code Found    Consume Charges: Y    Consume Units: Y    Treat zero Procedure Code Table amount as not found: N    Apply Mod50: Version 1 [[MOD 50]]    Additional Modifier Table: None    LSS reimbursement: N Plus:  FormulaCPE:   ({Charges In Service Type} - ({iv:FS Codes Charges} + {Charges In Pass-Through Section}))   * 75.00%  End FormulaCPE End Sum ; Zero instances of the item or service in the 15 months prior to posting the file.
DRILL BIT MED ATLANTIS ADJST,28610,CDM,0272,RC,,,,,,inpatient,facility,,,350,350,157.5,350,,,,,,,,,,,,,,,,,,,,297.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,248.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,245,,,percent of total billed charges,,,,,,210,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,297.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,262.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,350,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,157.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,297.5,,,percent of total billed charges,,,,,,,,,,,,,,
DRILL BIT MED ATLANTIS ADJST,28610,CDM,0272,RC,,,,,,outpatient,facility,,,350,350,66.5,1016,,227.5,,,percent of total billed charges,,,,,,,,,,,,,,,297.5,,,percent of total billed charges,,,,,,105,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 104.00% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Bundle Mod 91 Lab    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Apply Modifier CS    Apply IP-only Logic    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  30.00 % of Charges In Service Type ; Zero instances of the item or service in the 15 months prior to posting the file.,164.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480,,,case rate,,,,,,66.5,,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From and To Date Rule    Apply Modifier CT    Apply Modifier FX    Apply Modifier FY    Apply Modifier JG    Pay this percent instead of a zero amount: 19.00%    Number of retroactive years on weight adjustment: 0    Ignore the Device Code edit If ( Current Amount = 0.00 )   Then:  19.00 % of Charges In Service Type ,other,,,,0,Medicare OP Reimbursement:    Ambulatory Payment Classification (APC) pricing   Override total payment with 100% of Medicare total payment    Use this provider number in place of provider number from claim: 100034    Replace blank service dates with Service To date    Zero denied totals    Not doing APC bundling    Add Mod 25 to force payment    Ignore CCI edit 039    Ignore CCI edit 040    Ignore OCE edit 40 to force payment    Ignore Medicare From a